NR 571 Week 2 Myasthenia and Pneumonia Case Paper Example

Pneumonia in a 72-Year-Old With Generalized Myasthenia Gravis: A Multisystem Case Paper Organized Around the Decisions Rather Than the Organ Systems

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College of Nursing, Chamberlain University

NR 571: Complex Diagnosis and Management in Acute Care Practicum

Instructor Name

Month Day, Year

Pneumonia in a 72-Year-Old With Generalized Myasthenia Gravis: A Multisystem Case Paper Organized Around the Decisions Rather Than the Organ Systems

The Patient and the Admission

The patient is a composite drawn from the acute care service where I am placed this term. The patient is 72, a retired dental hygienist who lives with a spouse in a single-story house, gardens most days from April to October and drives. Generalized myasthenia gravis with antibodies against the acetylcholine receptor was diagnosed six years ago and has been stable for three on pyridostigmine 60 mg four times a day, prednisone 10 mg every morning and azathioprine 100 mg daily. Other conditions are atrial fibrillation on apixaban and metoprolol, type 2 diabetes on metformin with a last A1c of 7.4%, chronic kidney disease at stage 3a (estimated filtration rate 52) and osteoporosis treated with weekly alendronate since starting long-term prednisone.

The patient arrived with three days of cough, fever and breathlessness. The temperature was 38.6 C, pulse 118 and irregular, pressure 118/70, respiratory rate 24 and saturation 90% on room air, rising to 95% once 2 liters of oxygen ran through a nasal cannula. The chest film showed consolidation in the right lower lobe. The white count was 14.8, urea nitrogen 23 and glucose 246. The CURB-65 score was 2, for age and urea. The spouse added the detail that changed the admission: for two days the patient's eyelids had drooped by evening, and thin liquids had started to cause coughing.

Ranking the Problems

I ranked the problems on the first evening by what could cause the most harm in the next 48 hours, and I wrote down the finding that would move each one.

1. Community-acquired pneumonia, moderate. It is the reason for admission and the likely trigger for everything else. It moves down if the fever and oxygen need fall within 48 hours.

2. Myasthenia gravis with early worsening. Infection is the commonest trigger of a myasthenic crisis, and the drooping eyelids and new difficulty swallowing are early signs (Gilhus, 2016). It moves up if bedside breathing tests fall.

3. Swallowing difficulty with risk of aspiration, which links the first two.

4. Atrial fibrillation with a fast rate, driven by fever and infection.

5. Hyperglycemia, from infection on top of daily prednisone.

6. Chronic kidney disease, which shapes drug choices and doses.

7. Osteoporosis on alendronate, a carried problem that becomes active because of the swallowing difficulty.

Where the Managements Stop Fitting Together

Three points of conflict appeared in the first six hours, and each is described here with the recommendation that created it.

The first is the antibiotic. The joint ATS/IDSA guideline on adult pneumonia recommends, for a patient admitted to a general ward, either a beta-lactam combined with a macrolide or a respiratory fluoroquinolone alone; each is a strong recommendation (Metlay et al., 2019). Both macrolides and fluoroquinolones can worsen neuromuscular transmission in myasthenia, and fluoroquinolones carry a boxed warning for exactly this effect (Sheikh et al., 2021). The guideline itself offers a third route, a beta-lactam with doxycycline, for patients who cannot take either class, though only as a conditional recommendation on low-quality evidence (Metlay et al., 2019). Like every single-disease guideline, it was written for a population that mostly did not have the patient's other conditions (Boyd et al., 2005).

The second conflict is heart rate. The usual first step for a fast rate in atrial fibrillation is a beta blocker, and the patient already takes one. Beta blockers can also deepen myasthenic weakness, which raises the question of whether to give more of the drug or to rely on treating the fever and infection.

The third conflict is how to treat the myasthenic worsening itself. Raising the prednisone dose is the obvious step, but steroid benefit in myasthenia takes weeks to arrive, high starting doses can cause a temporary worsening, and more prednisone would push the glucose higher during an infection (Gilhus, 2016). Intravenous immune globulin or plasma exchange act within days but carry their own costs.

The Arrangement Being Run

After discussion with the attending physician and the neurology consultant, the plan on the first night was as follows.

Antibiotics: ceftriaxone with doxycycline, given through the vein while swallowing was impaired. The urinary antigen for Legionella was sent, because doxycycline is a weaker choice against it than the guideline's preferred drugs, and a positive result would reopen the decision.

Myasthenia: pyridostigmine continued at the home dose, given with the nasogastric route ready if swallowing failed. Bedside respiratory monitoring every four hours: a single-breath count and neck flexion strength, which correlate with formal vital capacity in myasthenia (Elsheikh et al., 2016), and formal forced vital capacity twice a day. Prednisone held at the home dose of 10 mg. Neurology to decide on immune globulin the next morning based on the overnight numbers.

Heart rate: metoprolol continued at the home dose without additional doses; fever control with acetaminophen and fluid to reduce the rate. Apixaban continued.

Glucose: metformin held because of the infection and kidney function; basal and correction insulin to a target below 180 mg/dL, in line with the inpatient hyperglycemia guideline (Umpierrez et al., 2012).

Swallowing: nothing by mouth until a speech-language pathology assessment; alendronate held, because it requires the patient to swallow a full glass of water and stay upright for 30 minutes, which was not safe.

What Changed by Day 3

On the morning of day 2 the single-breath count had fallen from 22 to 17 and the vital capacity from 1.9 to 1.5 liters. Neurology started immune globulin at 2 g/kg divided over two days, using a product without sucrose and a slow rate because of the kidney disease. By day 3 the fever had broken, the oxygen was off and the breathing numbers had stabilized. The Legionella antigen was negative, and the antibiotic plan stood.

What This Case Shows About Multimorbidity

In this patient, the conditions were not a list to be worked through one at a time. The pneumonia changed the myasthenia, the myasthenia changed the antibiotic, the antibiotic choice created a new test to send, and the swallowing difficulty reached all the way to an osteoporosis drug that had nothing to do with the admission. The guidelines for each condition were useful, and every one of them had to be qualified before it could be used. The American Geriatrics Society's guiding principles for multimorbidity ask clinicians to weigh the evidence in light of the patient's other conditions and to consider the interactions between treatments, which is what this admission required at almost every step (American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity, 2012).

References

American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. (2012). Guiding principles for the care of older adults with multimorbidity: An approach for clinicians. Journal of the American Geriatrics Society, 60(10), E1-E25. https://doi.org/10.1111/j.1532-5415.2012.04188.x

Boyd, C. M., Darer, J., Boult, C., Fried, L. P., Boult, L., & Wu, A. W. (2005). Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA, 294(6), 716-724. https://doi.org/10.1001/jama.294.6.716

Elsheikh, B., Arnold, W. D., Gharibshahi, S., Reynolds, J., Freimer, M., & Kissel, J. T. (2016). Correlation of single-breath count test and neck flexor muscle strength with spirometry in myasthenia gravis. Muscle & Nerve, 53(1), 134-136. https://doi.org/10.1002/mus.24929

Gilhus, N. E. (2016). Myasthenia gravis. New England Journal of Medicine, 375(26), 2570-2581. https://doi.org/10.1056/NEJMra1602678

Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., Cooley, L. A., Dean, N. C., Fine, M. J., Flanders, S. A., Griffin, M. R., Metersky, M. L., Musher, D. M., Restrepo, M. I., & Whitney, C. G. (2019). Diagnosis and treatment of adults with community-acquired pneumonia: An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. American Journal of Respiratory and Critical Care Medicine, 200(7), e45-e67. https://doi.org/10.1164/rccm.201908-1581ST

Sheikh, S., Alvi, U., Soliven, B., & Rezania, K. (2021). Drugs that induce or cause deterioration of myasthenia gravis: An update. Journal of Clinical Medicine, 10(7), Article 1537. https://doi.org/10.3390/jcm10071537

Umpierrez, G. E., Hellman, R., Korytkowski, M. T., Kosiborod, M., Maynard, G. A., Montori, V. M., Seley, J. J., & Van den Berghe, G. (2012). Management of hyperglycemia in hospitalized patients in non-critical care setting: An Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism, 97(1), 16-38. https://doi.org/10.1210/jc.2011-2098