Telithromycin and Myasthenic Crisis

Author(s): Alison M. Jennett, Doru Bali, Pallavi Jasti, Bhavish Shah and Linda A. Browning
Source: Clinical Infectious Diseases, Vol. 43, No. 12 (Dec. 15, 2006), pp. 1621-1622
Published by: Oxford University Press
Stable URL: http://www.jstor.org/stable/4485166
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we decided to administernonhyperimmune IVIGin the face of a progressively

worsening clinical status. Clinical improvementwas rapidand constantduring the courseof treatmentand resulted
in almost complete recovery.We think
thatthe benefitobservedwithIVIGtreatment in this patientcould have resulted
froman immune-modulation
effect-the
samethathas beenobservedin acutedisseminatedencephalomyelitis.
Thisis the firstcase,to our knowledge,
of the use of IVIG to treat JE. Additionalinvestigationsand clinicaltrialsare
warrantedbefore any recommendations
shouldbe made,but in our opinion,IVIG
may prove to be useful when administeredwith symptomatictreatmentforthis
deadlyand invalidatingdisease.

therapyin acute disseminatedencephalomyelitis. PediatrNeurol 1999;21:583-6.

orcorrespondence:
Dr.Pietro
di
Amedeo
Caramello,
Reprints
SavoiaHospital,
UnitA of Infectious
andTropical
Diseases,
CorsoSvizzera
164,10149Turin,
Italy(pcarame@tin.it).
ClinicalInfectiousDiseases 2006;43:1620-1
? 2006bythe Infectious
DiseasesSocietyof America.
All
1058-4838/2006/4312-0018$15.00
rightsreserved.

Telithromycin and
Myasthenic Crisis
To THE EDITOR-We read with interest

the letterby Niemanet al. [1] abouttelithromycinand myastheniagravis(MG).

Aventisreportedthatseveralpatientswho
had used telithromycinfor treatmentof
respiratoryinfectionhad experiencedexacerbations
of alreadydiagnosedMG,with
1 patientdeath [1].
Werecentlytreateda 46-year-oldwhite
woman with MG and hypertensionwho
Acknowledgments
presentedto the emergencydepartment
Potential conflictsof interest. All authors:no
with shortnessof breath.Shehad recently
conflicts.
visitedherprimarycarephysicianandwas
PietroCaramello,'
FrancescaCanta,' giventelithromycinfor a sinus infection.
RosannaBalbiano,'FilippoLipani,' While
driving home, she experienced
SilviaAriaudo,'MauraDe Agostini,'
shortness
of breath,whichwassuddenin
GuidoCalleri,'LucioBoglione,1
and
AntoninoDi Caro2 onset, and she immediatelysoughtmed'Infectious
andTropical
Diseases"A,"Amedeo
di ical attention. Her vital signs on preSavoiaHospital,
and21stituto
Nazionale
Turin,
per sentationwereblood pressureof 140/100
le Malattie
Infettive
Lazzaro
Spallanzani, mm
Hg, pulse of 120 beats/min,respiLaboratorio
di Virologia,
Rome,Italy
ratoryrate of 22 breaths/min,and pulse
oximetryon room air of 94%.The iniReferences
tial treatment administered in the
1. Solomon T. Flavivirusencephalitis.N Engl J
emergencydepartmentincluded methMed 2004;351:370-8.
ylprednisolone,diphenhydramine,and
2. Winter PM, Dung NM, Loan HT, et al. Proalbuterol and ipratropium nebulized
inflammatorycytokinesand chemokinesin hutreatmentsfor anaphylaxis.A reviewof
mans with Japaneseencephalitis.J Infect Dis
2004; 190:1618-26.
hermedicationsrevealedthepotentialfor
3. Hoke CH, VaughnDW, NisalakA, et al. Effect
MG exacerbationin patients receiving
of high-dose dexamethasoneon the outcome
telithromycin.Thepatientwasgivenglyof acute encephalitisdue to Japaneseencephalitis virus. J Infect Dis 1992;165:631-7.
copyrrolate(0.2 mg intravenously),and
4. SolomonT, Dung NM, WillsB, et al. Interferon her
symptoms appeared to improve.
alfa-2ain Japaneseencephalitis:a randomised
However,her respiratorystatussuddenly
double-blind placebo-controlledtrial. Lancet
2003;361:821-6.
began to decline,with a pulse oximetry
5. BayryJ, Lacroix-Desmazes
S, KazatchkineMD,
on room air of 70%-80%,and the deKaveriSV.Intravenousimmunoglobulinforincision
to initiaterapidsequenceintubafectious diseases:tailor-madeor universal[lettion was made. The patient was given
ter]?J Infect Dis 2003; 188:1610.
6. AgrawalAG, Petersen LR. Human immunopropofol and succinylcholinefor acute
globulin as a treatmentfor WestNile virus inrespiratoryfailurebefore intubation,as
fection. J Infect Dis 2003;188:1-4.
well as midazolam and vecuronium
7. NishikawaM, IchiyamaT, HayashiT, OuchiK,
Furukawa S. Intravenous immunoglobulin shortlythereafter.
The patientwas trans-

ferred to our institution and admitted to

the medical intensive care unit for myasthenic crisis (MC).
On day 2 of hospitalization, the acetylcholine receptor antibody level was found
to be 0.1 nmol/L (negative value, 0-0.4
nmol/L; positive value, ~0.5 nmol/L; values were determined at ARUP Labs [Salt
Lake City, UT]). The patient underwent
plasmapheresis on days 2 and 4 of hospitalization and was restartedon her normal dose of pyridostigmine (60 mg given
4 times daily) on the day of her second
plasmapheresis session. The patient underwent extubation and started receiving
methylprednisolone on day 3 of hospitalization. On the following day, methylprednisolone therapy was switched to
prednisone therapy (20 mg daily), with
the goal of increasing the dosage by 5 mg
every week, to achieve a daily dose of 60
mg. CT was also performed on day 5 of
hospitalization, and the results were negative for thymoma. The patient remained
in the medical intensive care unit for 5
days, and she was discharged from the
hospital after 8 days of hospitalization.
MG is an antibody-mediated autoimmune attackdirectedagainstnicotinic acetylcholine receptors at the neuromuscular
junction. These antibodies cause a reduction in acetylcholine receptors, resulting
in the inability to sustain or repeat neuromuscular contractions. The cardinal
features are weakness and fatigability of
skeletal muscles. If respiratory weakness
becomes severe enough to require mechanical ventilation, the patient is said to
be in myasthenic crisis [2].
Several drugs have been identified that
interfere with neuromuscular transmission. Symptoms commonly occur several hours to days after exposure to the
drug. Common antibiotic classesthat have
been associated with myasthenic crisis
include aminoglycosides, macrolides, 0lactams and monobactams, and quinolones. Extensive reviews of drugs that

affect neuromusculartransmissionare
availableelsewhere[3, 4].
(Ketek;Aventis)wasthe
Telithromycin

CORRESPONDENCE* CID 2006:43 (15 December) * 1621

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first member of the ketolide antibiotic

class, and it receivedapprovalfrom the
US Food and Drug Administrationin
2004 [5]. The manufacturerrecentlyreleaseda statementthat warnedclinicians
to exerciseextremecautionwhen giving
telithromycinto patientswith MG. The
warningfrom AventisPharmaDeutschland reportedthat severalpatientswho
had usedtelithromycinfor respiratory
infectionshad experiencedexacerbations
of
with
1
MG,
patient
alreadydiagnosed
death.Accordingto the report,patients
experiencedan intensificationof muscle
weakness,dyspnea,or "heavybreathing"
within hours after taking telithromycin
[6]. A reviewof the Aventissafetydatabase revealed8 cases of MG exacerbation [1].
Althoughour patientdid receivesuccinylcholineandvecuronium(neuromuscular blocking agents), her symptoms
began to appear immediatelyafter she
ingestedtelithromycin.Telithromycinis
not recommendedfor patientswith MG
[5]. This case illustratesthat clinicians
shouldbe awareof this potentialadverse
effect and differentiatebetween myasthenic crisisversusreactionsresembling

5. Ketek(telithromycin)[packageinsert].Kansas
City,MO: Aventis,2004.
6. Reuters. Aventis urges extreme caution with
Ketek in patientswith myastheniagravis [editor's comments]. Clin Infect Dis 2003;36:ii.
or correspondence:
Dr.LindaBrowning,
Reprints
Dept.of
4201St. AnService,Detroit
Pharmacy
Hospital,
Receiving
Ml48201(Ibrownin@dmc.org).
toine,Detroit,
ClinicalInfectiousDiseases 2006;43:1621-2
? 2006bytheInfectious
DiseasesSocietyof America.
All
1058-4838/2006/4312-0019$15.00
rightsreserved.

anaphylaxis.
Acknowledgments
Potential conflictsof interest. All authors:no
conflicts.

AlisonM. Jennett,'1DoruBali,3
PallaviJasti,24BhavishShah,24
and
LindaA. Browning'1
of Pharmacy
2Detroit
Services,
'Department
andUniversity
HealthCenter,
Receiving
Hospital
Detroit
of
Medical
andDepartments
Center,
Medicine
and4Medicine,
3Emergency
Detroit,
WayneStateUniversity,
Michigan
References
1. Nieman RB, EdelbergH, Caffe SE. Telithromycin and myastheniagravis [letter].Clin Infect Dis 2003;37:1579.
2. Richman DP, Anius MA. Treatmentof autoimmune myastheniagravis.Neurology 2003;
61:1652-61.
3. Wittbrodt ET. Drugs and myastheniagravis.
Arch Intern Med 1997;157:399-408.
4. Barrons RW. Drug-induced neuromuscular
blockadeand myastheniagravis.Pharmacotherapy 1997;17:1220-32.

1622 * CID 2006:43 (15 December) * CORRESPONDENCE

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