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Dr. Bob
Dr. Bob, Neurologist (MD)
Category: Neurology
Satisfied Customers: 6694
Experience:  Neurology & Int Medicine (US Trained): 20 yrs experience
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I need a specialist in Myasthenia Gravis, please

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Hi
I need a specialist in Myasthenia Gravis, please

Hello. What is your question?

Customer: replied 1 month ago.
Hi
Thanks.
Customer: replied 1 month ago.
myasthenia Gravis
History:
62 years old female with 1.5 years symptoms diagnosed 1 month ago with MG.
Symptoms started with unilateral ptosis and double vision around 1.5 years ago and the patient stated on Acetazolamide.
Then after one year she had episode of fever and severe Flu like symptoms, and ptosis and double vision started in the other side. She then started on steroids.
Symptoms progressed with problems with swallowing and started on Myestin tablet. Then she developed breathing problems and admitted to ICU with 5 days infusion of IVIG with not much improvement. Followed by plasmapheresis. After 5 days of plasmapheresis she had significant improvement with regards to swallowing, voice and limbs movements.
She then discharged home.
Doctors suggested thymus operation and Rituximab. The family not sure how effective will be the thymus operation or/and Rituximab.


Medical problems:
Familial heart problems and aortic valve stenosis. AF , Hypertension, high cholesterol, Diabetic type2, right breast cancer (mastectomy and lymphadenectomy), Right breast cancer (mastectomy only), no further recurrence of breast cancer. Kidney stones because of Acetazolamide


Investigation:
Brain MRI normal, CT chest normal,LP normal, Blood results available if you need

Your opinion:
?Operation
? any medication
For Thymus operation they need contrast study first
How much success id with thymus operation or Rituximab
Any other medications you aware ?

Hi there. Removing the thymus gland can be very helpful for those 10 to 15 percent of patients with MG associated with thymoma. There are risks associated with surgery, of course, so thymectomy should be managed by the surgeon in close collaboration with anesthesiology and a neurologist.

Customer: replied 1 month ago.
thank you
What about Rituximab? is their any indication or contra indication in this patient for this medication?
Any other treatment `available to help?

Studies do suggest that Rituximab treatment offers some benefit for adult patients with MG, and that quality of life measures improve overall.

It also tends to reduce the need for prednisone.

Customer: replied 1 month ago.
Any other treatment if such a patient comes to your clinic you might offer ?

In general, side effects were few in the studies but more studies are underway to look at this with larger populations.

These would be the main considerations in those that do not tolerate or do not benefit from IVIG and/or plasma exchange.

Have they tried pulsed intravenous methylprednisolone? That would be another option for moderate exacerbations. This is typically followed by oral prednisone to keep symptoms under control.

Average duration of improvement with this option is about 8 weeks.

Customer: replied 1 month ago.
She is on prednisone but i will suggest to check for Pulsed intravenous if they haven't tried
Any tests to show if thymectomy beneficial for the patient prior to operation?

Surgery is indicated in about 10-15% of those with MG associated with a thymoma. If she falls into this sub-classification, according to her neurologist, then it would make sense. They might want to obtain a tissue sample via biopsy to make a definitive diagnosis prior to surgery. One study with 200 patients who underwent thymectomy found that less than 10% were in remission after a mean follow up of 10 years, and about 80% were still requiring immunosuppression.

Dr. Bob and other Neurology Specialists are ready to help you
Customer: replied 1 month ago.
Thank you
Can I summarise that in her case because she responded well to plasmapheresis Rituximab might not be very helpful?
And for surgery up to her neurologist +/_ biopsy results
and continue with prednisone Pulsed intravenous?

She had IVIG prior to the plasma exchange, so it would be hard to say which one worked. The beneficial effects of IVIG can take up to 5 weeks to kick in. Either way, if she does respond well, and the response is sustained, one could argue this should be done with each flare. The Rituximab may not be necessary. On the other hand, a trial would be reasonable as IVIG and plasma exchange are expensive and inconvenient (and somewhat invasive). And yes, the thymectomy is a call best made by her neurologist after considering all the various factors in her clinical situation and all the risks and potential benefits.