Friday June 13, 2008


Q: You have been called to ED to evaluate 46 year old male with probable exacerbation of Myasthenia gravis (MG). Patient is still protecting his airway. Though you arrange intubation at bedside, you decide to give Tensilon (edrophonium) challenge test. As soon as you administer 3 mg of edrophonium, patient develops increase salivation, bronchopulmonary secretions, became diaphoretic, and smelled to have flatus (symptoms of SLUDGE syndrome *). You required to intubate the patient. What's your diagnosis?


Answer: Cholinergic crisis

One of the confusing factors in treating patients with Myasthenia gravis is that insufficient medication (ie, myasthenic crisis) or excessive medication (ie, cholinergic crisis) ?

In patient with myasthenic crisis, muscular strength will improve with edrophonium, otherwise there will be no response or weakness will increase along with unmasking symptoms of cholinergic crisis (SLUDGE syndrome *).

Cholinergic crisis is seen in patients with myasthenia gravis who take too high a dose of their cholinergic treatment medications. As a result of cholinergic crisis, muscles stop responding to the bombardment of ACh, leading to flaccid paralysis, respiratory failure, increased sweating, salivation, bronchial secretions and miosis.

Tensilon (edrophonium) challenge test is good way of differentiating between myasthenic crisis (insufficient medication) and cholinergic crisis (excessive medication).



SLUDGE = Salivation, Lacrimation, Urinary Incontinence, Diarrhea, GI hypermotility, Emesis


Related previous Pearls:

Iodinated IV contrast and myasthenia gravis

Ice test - Poor man's test for Myasthenia Gravis