![]() 6,7Īmong few other pharmacologic options remaining, mirtazapine and mianserin are atypical tetracyclic antidepressants used off-label for insomnia and acute anxiety, given their histamine H1 receptor blocker activity with almost no anticholinergic effects. Moreover, antipsychotics were also incriminated in worsening of MG and may be confusing to use in this context since myasthenic crisis may be mistaken for antipsychotic-induced extrapyramidal syndromes. Sedative antipsychotics are the second option but were not used since the patient was still monitored and treated for cardiac rhythm disorders, which also may constitute a contraindication to antipsychotics. MG is known to be an absolute contraindication to benzodiazepines and nonbenzodiazepine anxiolytics such as hypnotics, which constitute the first-line treatment for acute and severe insomnia and anxiety. In this case, it was necessary to control the patient’s anxiety symptoms to relieve her distress and to give extubation attempts the maximum chance for success. 4 Management of such symptoms may be challenging for practitioners given the constraints that MG presents with anxiolytics and hypnotics (Z-drugs). Anxiety in patients on respiratory assistance can be particularly problematic and may be related to fear of suffocation and reluctance to be extubated. 3 All these psychiatric disturbances are usually associated with sleep problems. 2 PTSD is also observed after respiratory insufficiency in patients with MG. They usually consist of anxiety disorders such as panic disorder and generalized anxiety disorder and depressive disorders. Psychiatric comorbidities in patients with MG are rarely studied. ![]() After being discharged, the patient maintained regular follow-up with her neurologist. She was transferred to the neurology ward and stayed for 10 days and then left the hospital. After augmentation to 30 mg/d, the frequency and intensity of the panic attacks decreased, allowing for extubation, and mianserin was tapered and stopped at the request of the patient after she left the intensive care unit. She experienced no adverse effects and a partial response: only sleep was improved. Therefore, she was given mianserin at an initial dose of 15 mg/d. We concluded that she was experiencing panic attacks triggered by the worsening of the respiratory condition, with anticipatory anxiety about being short of breath. She did not meet DSM-5 criteria for posttraumatic stress disorder (PTSD), postpartum depression, or postpartum psychosis. Five days after the failure of the first extubation attempt, she exhibited insomnia, acute anxiety, sensation of imminent death, and recurrent tachycardia. The patient spent 29 days in the intensive care unit. She maintained spontaneous breathing after extubation 72 hours after the last session. She finally responded after 5 sessions of plasmapheresis. She subsequently underwent extubation and reintubation procedures 3 times. Her condition did not improve, and she could not maintain spontaneous breathing. ![]() Initial treatment consisted of intravenous immunoglobulins (2 g/kg over 5 days) with prednisone (20 mg/d) and pyridostigmine (30 mg 3 times/d). She was diagnosed with myasthenia crisis. She had her first episode of cardiorespiratory arrest during a computed tomography angiography procedure and was placed under endotracheal intubation and ventilation. Case ReportĪ 40-year-old woman, with no psychiatric history but previously diagnosed with generalized MG, presented to the emergency department 18 days after she delivered her first child with fatigue, diplopia, unilateral ptosis, progressive shortness of breath, and swallowing difficulties. 1 In the context of severe respiratory symptoms or respiratory failure, management of acute insomnia and anxiety is a therapeutic challenge with limited pharmacologic options. At the same time, anxiety and insomnia are frequently observed in severe forms of MG. Myasthenia gravis (MG) is one of the rare contraindications of anxiolytics and hypnotics.
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