Journal of Clinical Case Reports

Pyridostigmine-Induced High Grade SA-Block in a Patient with Myasthenia Gravis

Abstract

Sarmad Said, Haider Alkhateeb, Chad Cooper, Sherif Elhanafi, Sayeed Khalillullah, Sucheta Gosavi and Zainul Abedin

Myasthenia gravis requires a long-term treatment with a parasympathomimetic agent, which may result in bradycardia and asystole. Pharmacologic treatment with a reversible inhibitor of Inosine Monophosphate Dehydrogenase (IMPDH) and Methylprednisolone are seen to improve the muscular symptoms but may reinforce potential bradyarrhythmias. This potential side effect can be treated with the levo isomer of atropine, Hyoscyamine, or Glycopyrollate in an intact conduction system. Case presentation:A 70-year old Caucasian female patient with a family history of myasthenia gravis presented with mild weakness of the bilateral facial muscles, moderate dysarthria, dysphagia, diplopia predominantly on the right side and difficulty tracking ocular movements bilaterally. The treatment with pharmacological agents was initiated. Subsequently she developed asymptomatic bradycardia and SA-block. An improvement on Hyoscyamine failed to appear. A dual chamber pacemaker was placed. Conclusion: In symptomatic bradycardia or asymptomatic, however, significant high grade SA-block in patients with myasthenia gravis the insertion of a permanent pacemaker can be the definitive solution.