Myasthenia Gravis, Schizophrenia, and Colorectal Cancer in A Patient: Long-Term Follow-Up with Medication Complexity
Ms A, a 46-year-old woman, diagnosed as disorganized type schizophrenia when she was 20 years old in 1985, was frequently hospitalized to the psychiatric ward and showed poor response to medication. At age 35, she was hospitalized for pneumonia and acute respiratory distress syndrome (ARDS), and at 38, she was hospitalized 2 times for dyspnea associated with pneumonia.\nAt 39, her fourth ARDS occurred after infectious symptoms of the upper respiratory track. Based on clinical symptoms, such as repetitive respiratory failure, ptosis, and dysphonia, MG was suspected and diagnosis was confirmed by tensilon tests, as well as detecting antibodies for acetylcholinesterase. In order to exclude MG with thymoma, mediastinal computerized tomography (CT) was taken and there were no sign of thymoma. Respiratory failure was improved by administrating pyridostigmine and immunosuppressants after plasmapheresis, and afterwards, Ms A was transferred to a chronic mental hospital.\nAt 42, respiratory failure recurred. Despite additional 15 mg of prednisolone, symptom was aggravated and she was transferred to the department of psychiatry, Kyung Hee University Hospital (KHUH). After maintaining the additional dosage, respiratory symptom was relieved and she was transferred back to the chronic mental hospital.\nIn January, 2011, respiratory failure symptoms recurred, and the patient was hospitalized at the intensive care unit of KHUH. Along with the administration of additional 10 mg of prednisolone, plasmapheresis and high dosage steroid pulse therapy were carried out and dyspneic symptom was stabilized. Aripiprazole 15 mg, paliperidone 6 mg and quetiapine 1200 mg was being administrated for psychiatric symptom control from the transferred hospital. However, in order to avoid potential drug interactions, only quetiapine 1200 mg was administrated through the nasogastric tube. Afterwards, psychotic symptoms aggravated. As persecutory and somatic delusions, as well as insomnia continued, the patient was moved to the psychiatric ward and haloperidol was added up to 10 mg. After increasing the dosage of haloperidol, lower extremity tremor, which seemed to be one of the symptoms of extrapyramidal syndrome (EPS), was observed, and procyclidine, an anticholinergic, was added. Three weeks later, the patient showed respiratory distress, with particular aggravation during night time. This was thought to be caused by exacerbation of myasthenia gravis due to administration of anticholinergics. Then, anticholinergics were stopped. Afterwards, dyspnea, somatic and persecutory delusions got worse at night and had trouble falling asleep. The patient's symptoms were suspected to be exacerbation of schizophrenia or sleep disorder due to respiratory muscle fatigue from MG. While the patient complained of insomnia, arterial blood gas analysis was tested and showed normal results. Chest X-rays were filmed because of frequent respiratory infections and atelectasis history and mild atelectasis was seen at the left lower lobe of the lung. Therapy with spirometer was considered, but postponed concerning respiratory muscle fatigue. MG exacerbation was suspected as ptosis and hoarseness symptoms worsened, and maintenance therapy with 10 mg prednisolone was carried out without dose reduction. For aggravated symptoms of schizophrenia, such as day time emotional fluctuation and aggravated persecutory delusions, haloperidol was increased to 20 mg and chlorpromazine 50 mg was added for sleep control. Overall symptoms improved after 130 days of hospitalization and Ms A was discharged.\nFour months after discharge, in order to evaluate severe anemia, she was transferred to KHUH and underwent a colonoscopy. Biopsy specimen was diagnosed as colorectal cancer. After surgical resection in the colon, she was hospitalized to the psychiatric ward for 2 weeks, and afterwards, Ms A was discharged to a chronic mental hospital.