Henry R. Viets, MD, and the history of myasthenia gravis

Henry R. Viets (1890–1969) was both a noted neurologist and medical historian. While at Harvard Medical School, from which he graduated in 1916, he attracted the attention of Harvey Cushing who directed Viets into these disciplines. Cushing arranged for Viets to take a fellowship in Oxford in the year after his graduation. With Cushing's recommendation, he lived with Sir William and Lady Osler and did research with the famous neurologist Sir Charles Sherrington. Viets was in London in 1935 when he heard about the remarkable success of Mary Walker in treating myasthenia gravis, first with physostigmine and then with neostigmine (Prostigmin). Securing an ampoule of this drug, he took it to the Massachusetts General Hospital where he was an attending neurologist and in March 1935 injected it into a myasthenic patient with great success. He established the first Myasthenia Gravis Clinic in the world and was a pioneer in the treatment of this once obscure disease: he evaluated hundreds of patients and published many articles on myasthenia. He continued this association for over 30 years. Under the tutelage of Cushing and Osler, Viets became a medical historian and bibliophile, publishing hundreds of articles and several books on many different subjects in the history of medicine. He was the President of the American Association for the History of Medicine and curator of the Boston Medical Library that eventually joined with the Harvard Medical School Library. Viets served on the Editorial Board of the New England Journal of Medicine for 40 years.

A Rare Association between Myasthenia Gravis and a Growth Hormone Secreting Pituitary Macroadenoma: A Single Case Report

Myasthenia Gravis (MG) is a chronic autoimmune neuromuscular disease. Although it is well known that patients with myasthenia gravis have a higher incidence of other autoimmune disorders, however, its association with pituitary adenomas is extremely rare. We believe that our case represents the 8th of this association and the 2nd case involving a GH-secreting adenoma. Here we report a case of a 45-year old Syrian woman who presented with typical complaints of myasthenia gravis as she was suffering from variable painless and effort-related dysphagia and dysarthria. Her complaints became more evident at the end of the day, while acromegaly only manifested as a 4-month history of headache and a special facies that was noted by the physician. Brain MRI scan demonstrated a 3.21 x 2.42 x 2.35 cm pituitary mass for which the patient underwent a trans-sphenoidal pituitary tumor resection. In addition, postoperative histopathological investigations confirmed the diagnosis of a GH-secreting macroadenoma. On following up, it was observed that her myasthenic symptoms improved significantly on Pyridostigmin and Prednisolone. In conclusion, the presence of headache in a myasthenic patient should raise the attention for other underlying causes including pituitary tumors.

Respiratory Arrest after Postoperative Extubation in a Myasthenic Patient who Received Sugammadex to Reverse Neuromuscular Blockade

Postoperative myasthenic crisis is common after thymectomy; the incidence ranges from 12 to 34%. Several factors are known to predict myasthenic crisis and increased risk necessitating postoperative mechanical ventilation, but incomplete postoperative reversal cannot be prevented perfectly. Sugammadex is a medicine that reverses neuromuscular blockade, and can be used to facilitate the return of spontaneous respiration in myasthenic patients. It was recently reported that myasthenic patients rapidly recovered neuromuscular function when sugammadex was used. An 81-year-old, 49 kg woman diagnosed with myasthenia gravis one month previously was admitted for intravenous immunoglobulin G treatment and thymectomy. After thymectomy the patient suffered a myasthenic crisis and respiratory arrest, despite administration of sugammadex to reverse the neuromuscular blockade.This case suggests that more careful and strict evaluation and management should be conducted perioperatively in myasthenic patients, and that the recovery time (time to obtain a train-of-four [TOF] value > 0.9) and spontaneous breathing trial results should be obtained to accurately predict the success of spontaneous breathing.