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Pyridostigmine-induced coronary artery spasm in early-onset myasthenia gravis: a case presentation and review of the literature
  1. Oranuch Chuapakdee1,
  2. Tanit Layangkool2 and
  3. Nonthikorn Theerasuwipakorn3
  1. 1Division of Neurology, Department of Medicine, Sunpasithiprasong Hospital, Ubon Ratchathani, Thailand
  2. 2Division of Cardiology, Department of Medicine, Sunpasithiprasong Hospital, Ubon Ratchathani, Thailand
  3. 3Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Cardiac Centre, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
  1. Correspondence to Dr Nonthikorn Theerasuwipakorn; n.theerasuwipakorn{at}


We present a case of pyridostigmine-induced coronary artery spasm in a woman with early-onset myasthenia gravis (MG) who suffered from acute chest discomfort a few days after pyridostigmine dose up-titration. Twelve-lead ECG demonstrated ST-segment elevation in inferior limb leads together with sinus arrest. Sublingual nitrate was immediately given, which rapidly relieved her symptoms concomitantly with the resolution of abnormal ECG findings. Coronary angiography showed normal coronary arteries reflecting the transient nature of the disease. A small dose of pyridostigmine was rechallenged under close monitoring in the coronary care unit and reproduced her chest discomfort. After the substitution of pyridostigmine with immunosuppressive agents and prescription of long-acting nitrate, she had no recurrence of chest discomfort, as well as well-controlled MG symptoms.

  • Arrhythmias
  • Ischaemic heart disease
  • Neurology (drugs and medicines)
  • Neuromuscular disease
  • Unwanted effects / adverse reactions

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  • Contributors OC participated in the conception of the work, data acquisition and drafting of the manuscript. TL contributed to image acquisition and interpretation. NT participated in the conception of the work, figure preparation, editing and revising the manuscript. All authors read and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.