How is a cholinergic crisis differentiated from a myasthenic crisis in myasthenia gravis?

Updated: Sep 20, 2018
  • Author: William D Goldenberg, MD; Chief Editor: Andrew K Chang, MD, MS  more...
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One of the confusing factors in treating patients with myasthenia gravis is that insufficient medication (ie, myasthenic crisis) and excessive medication (ie, cholinergic crisis) can present in similar ways.

Cholinergic crisis results from an excess of cholinesterase inhibitors (ie, neostigmine, pyridostigmine, physostigmine) and resembles organophosphate poisoning. In this case, excessive ACh stimulation of striated muscle at nicotinic junctions produces flaccid muscle paralysis that is clinically indistinguishable from weakness due to myasthenia gravis. Despite muscle weakness, deep tendon reflexes are preserved.

Both myasthenic crisis and cholinergic crisis may cause bronchospasm with wheezing, bronchorrhea, respiratory failure, diaphoresis, and cyanosis. [9]

Miosis and the SLUDGE syndrome (ie, salivation, lacrimation, urinary incontinence, diarrhea, gastrointestinal [GI] upset and hypermotility, emesis) also may mark cholinergic crisis. However, these findings are not inevitably present.

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