Brief Answer:
Needs management

Detailed Answer:
Thank you for asking!
From your presentation, it seems that your husband has most likely a grade 2 myasthenia gravis. His neurologist did the right thing by putting him on prednisone and immunomodulators like azathioprine.Azathioprine and all other sister immunomodulators like cyclosporine,cyclophosphamide, mycophenolate mofetil, rituximab etc has the ability like all other immunomodulators to lower the leukocyte count causing leukopenia and in rare cases lymphoma and skin cancer. But as you mentioned his both parents had malignancy then i am sure he needs a little screening yearly to stay out of the woods. Because god forbid if he gets it, it would not be azathioprine but his genes.
He is using 100 mg of it in a day almost a gram or two per kg which is perfectly fine.
Now other than these steroids and immunomodulating azathioprine there are many other pharmacological options like
1-Anticholinesterase Inhibitors eg Pyridostigmine bromide (Mestinon, Regonol), Neostigmine (Prostigmin), Edrophonium (Enlon)
2-IVIGs Intravenous immunoglobulins
3-Beta 2 agonists like Albuterol, salbutamol (Proventil, Ventolin, ProAir)
4-Respiratory anticholinergics like Ipratropium (Atrovent),Glycopyrrolate (Robinul, Cuvposa)
5-Plasmapheresis
6-Minimal invasive robotic thymectomies.
You husband may experience difficulty chewing and swallowing because of oropharyngeal weakness. It may be difficult for the him to chew meat or vegetables because of masticatory muscle weakness. If dysphagia develops, it is usually most severe for thin liquids because of weakness of pharyngeal muscles. To avoid nasal regurgitation or XXXXXXX aspiration, liquids should be thickened.

Educate him about the fluctuating nature of weakness and exercise-induced fatigability. He should be as active as possible but should rest frequently and avoid sustained physical activity.
Hope it helps.Stay in touch with your neurologist and the interventional cardiologist ( as he had a history of angioplasty) and get them help you and discuss the above mentioned options with him too. Dont forget to close the discussion please.
May the odds be ever in your favour.
S Khan

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Brief Answer:
:)

Detailed Answer:
Thank you for asking!
You heard just right.Beta blockers does that and that is why they shoul dnot be the antihypertensive drug of choice for MG patients. Discuss it with my name friend and find a friendly replacement. Lower lymphocytes are already explained , It is due to the immunomodulation by steroids and azathioprine. So all understandable. Yes in my knowledge all the six option i mentioned in my previous answer including Anticholinesterases and immunosuppressants wok fine. Some are reserved for flare ups like IVIG.
Now the last question is tricky regarding prednisone duration. If i were the doctor of his, i would keep the dose regimen to minimum duration possible. These agents are usually given over 1 or 2 years before tapering is begun.But it takes usually 1 to 4 months for the titre to fall. Also alternate day regimen would be better and all the pills in the early morning with hormonal surges in pattern with the circadian rhythms to prevent adverse effects. Nut shell. 7 to 8 weeks, alternate day regimen, slow tapering and all in the morning dose is advised.
Stay in touch with your doctor and consider his words like a bible and mine like a side kick with no orientation. As he knows the best for having a complete clinically correlated perspective of your husband and me having all together some keys of a key board and a lot of spare time to answer and answer and answer :P
Take good care of your husband. Best wishes
Khan

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Brief Answer:
Hope for the best

Detailed Answer:
Hello again!
Losartan and metoprolol are lifelong meds and they are to be taken till the end until and unless the doctor replaces them with an alternative. Dose reshuffling is even not advised without consult. As hypertension is not curable disease.It is manageable one and it needs lifelong management.
And prednisone is good.10 mg is good. we already talked about its intake, how to, how much to and when to take. And we also discussed that usually it is reserved for exacerbations and once it is taken it reduces the titre back to normal in 1 to 4 months and stays that way for quite a while.
Don't worry steroids are enough to respond to in grade 2 myasthenias. The options i mentioned are 50 % reserved for exacerbations. Most conditions get alleviated with by mere steroids and prophylactic thymectomies. So dont worry, exacerbations wont be an issue in a near future. And lifestyle and daily routine precautions we discussed will make it more unlikely.So cheers.
And your doctor is right. Every drug is a poison and every poison is a drug. So whatever doctor decides about the medicines intake and amount. that decision will be in the best interest of your husband.
I am happy for the diplopia resolution. Limping leg might need a rheumatologist, as some time inflammation is severe and prednisone is not enough.
Nut shell, you deserve the applause for being the wife of millenium for so caring of your husband.May every husband gets a replica of you.
Take good care of yourself and hope for the best.
My wishes will be with you in their best possible form.
Regards
S Khan

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Brief Answer:
Labs show mild neutrophilia,mild infectio i guess

Detailed Answer:
Thank you for asking!
Glucose is fine. Neutrophils are 90 % which means an active inflammatory process. Lymph glands have lymphocytes and their reduction is quite explained by recent use of immunomodulators . They lower the immunity and thus lymphocytes. Segmented neutrophils are mature neutrophils and they indicate a little increase in number AKA neutrophilia and it indicates active inflammation. Dont worry. It is not that hazardous to be overwhelmed with. A little infection is the most likely interpretation of these recent labs and needs a clinical correlation. Lets wait for the neurologist opinion today and let us see what he has to say. Keep me posted.
Take care of both of yourselves.
Khan

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Brief Answer:
Best case scenario, lucky husband

Detailed Answer:
Thank you for asking!
The doctor is right about prednisone, It is best amongst all other options considering the side effect profile. Yes prednisone is an immunomodulator and that makes its working like charm in autoimmune conditions including MG. Thank you for complimenting my work. Ingrowing toe nail should be got rid of and is the best approach with future avoidance of care in trimming nails and trimming them in u shaped while sparing the edges as they grow deeper inside the toe and lead to such issues. Nothing works other than removing of the toenail which is an easy process under local anesthetics. Dont be that decrease might be due to shift of the synthesis of white blood cells to recent toenail in guise of neutrophils. ANd as i mentioned already in my first post i recommend alternate day regimen of steroids and at low dosages and slow weaning to prevent steroids induced hormonal imbalances of corticotropic axis. Slowly tapering the steroids is wise and should be used. We can not risk prolonged use of steroids complications for a little odd of recurrence of MG which is least likely providing all the flares and precautionary measures we discussed at start from exercise to diet and lifestyles and prophylaxis. And there are some things age related , which human beings are not able to combat with. Advancing age is one of them as it decreases the age . it is evolutionary process and it is the way it is. We can do our best with little care for worst case scenarios.
Nutshell, Everything is fine like it should be to the best possible case scenarios. Stop worrying about recurrences. We discussed that after a few months steroid use, the odds are decreased quite a bit. Stay compliant with the medicines and stay in touch with the neurologist. As he seems a good one and competent one like me :P
I hope it helps. I will be here if you ever need me.
may the odds be ever in your cute couple's favour.
Regards
Khan

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Brief Answer:
No worries, you are fine

Detailed Answer:
Thank you madam!
I appreciate your energy boosting response. I will be here for mondays updates of podiatrist. Now lets talk about you. Hypotension is worth worrisome if it falls below 80/ 55. And thus you are out of the woods. Your height and weight for the age are perfect so no worries in that regard.Also it is good omen to have all work up normal at age of 71. The skipped beats and PVCs of that extent are not that worrisome but it is better and wise to get an electrophysiologist opinion and let him sort out the plan. Could be ablation dependent or could be managed conservatively. As it has been a chronic process i would say conservative would work. As prescribed beta blockers, and regarding side effects lets make these blockers Beta 1 specific like carvedilol and bisoprolol. ANd the other doctor about not taking it at all is also right to XXXXXXX extent. Your choice taking selective beta blockers at low dosages or not taking them at all is you choice. Both will be ok to choose from. And stay away from xanax. It is addicting sedative hypnotic and i suggest it to only psychotic patients who have difficulty sleeping and lifestyle. ANd you are not amongst those obviously.
Anxiety and stress themselves cause a lot of palpitations and small prolapses make them more likely. Super added by stimulants like caffeine and cola beverages and alcohol etc which makes the palpitations more. Modifying diet and lifestyles with avoiding stimulants would work like charm.Take selective beta blockers in low dosages and you wont have to worry about. It will work as both anxiolytic as well as palpitations reliever.
Your husband i a loving man to insist such a necessary appointment. It can wait till may end.
In nutshell, Enjoy the colors of life, avoid stress and anxiety, modify diet and lifestyle, slight beta blockers, caring and accepting the limitations of a geriatric age of 71 and doing as directed by your doctor would keep you out of the woods. Right now there is no such thing to worry about. It is easily manageable and controllable. You just need to be compliant with what i said.
I hope it helps. You are my favourite patient who listens to me like a bible. A quality physician likes in his patient the most.
Regards
S Khan

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Brief Answer:
:)

Detailed Answer:
Thank you for the update!
Ingrown toenail should have been removed with the local anesthesia as option number one by your doctor which i mentioned already. It spares a lot of trouble and effort and within a few days everything gets back to normal.
And now the confession has been made in non compliance of medicines, The recurrence of diplopia is pretty obvious. Continue him on prednisone and get him in touch with the neurologist and make the confession there too.So that a management plan is accordingly set further. Compliance is the key here.
Now your palpitations. Yes palpitations can be due to the autonomic dysfunctions secondary to this mitral valve prolapse. but usually they are associated with genetically inherited MVP and not the acquired ones later in life.
Palpitations can be classified according to the rate, rhythm, and intensity of heartbeat,extrasystolic palpitations, tachycardiac palpitations, anxiety-related palpitations, and pulsation palpitations etc.
Also Certain symptoms and circumstances associated to palpitations are often connected with the various causes of the palpitations and may be very helpful in making differential diagnoses. for example Palpitations arising after sudden changes in posture are frequently due to intolerance to orthostatic or to episodes of atrioventricular nodal reentrant tachycardia. The occurrence of syncope or other symptoms, such as severe fatigue, dyspnoea, or angina, in addition to palpitations, is much more frequent in patients with structural heart disease. However, syncope may also occur at the onset of supraventricular tachycardia in patients with a normal heart, as the result of the triggering of a vasovagal reaction.

Polyuria i.e increase in urine frequency and volume which is due to the hypersecretion of natriuretic hormone, is typical of atrial tachyarrhythmias, particularly atrial fibrillation. By contrast, the sensation of a rapid, regular pulse in the neck (usually associated with the 'frog sign') raises suspicion of supraventricular tachycardia, particularly atrioventricular nodal reentrant tachycardia. It is the result of atria contracting against closed tricuspid and mitral valves. An atrioventricular mechanical dissociation may also occur in the case of ventricular extrasystoles. In this case, however, only one or few pulses are felt in the neck, and the rhythm is more irregular. In supraventricular tachycardias involving the atrioventricular node, patients often learn to interrupt the episode by themselves by applying vagal stimulation through Valsalva's manoeuvre or carotid sinus massage.

Palpitations that arise in situations of anxiety or during panic attacks are generally due to episodes of more or less rapid sinus tachycardia secondary to the mental disturbance. In some cases, however, the patient may have difficulty in discerning whether the palpitations precede or follow the onset of the anxiety or panic attack, and may therefore be unable to suggest whether the palpitations are the cause or the effect of the psychological distress.

During physical exercise, due to an increase in the sympathetic drive, patients may experience, in addition to the normal sensation of a rapid heart rate elicited by intense effort, palpitations due to various types of arrhythmia, such as right ventricular outflow tract tachycardia, atrioventricular node reentrant tachycardia, and polymorphic catecholaminergic ventricular tachycardia. Finally, episodes of paroxysmal atrial fibrillation may occur in the phase immediately following the cessation of physical effort, during which a sudden reduction in sympathetic tone is accompanied by an increase in vagal tone.

Now irrespective of the cause lets discuss its management.Therapy for palpitations is, of course, directed towards the aetiological cause (i.e. treatment of cardiac arrhythmias, structural heart diseases, psychosomatic disorders, or systemic diseases) whenever it can be determined. However, many of the suggestions that can be made are based on clinical experience, without scientific documentation to rely on.

When a clear-cut aetiology is established and a low-risk curative therapy is available (e.g. ablation for supraventricular arrhythmias), there is no doubt that this is the treatment of choice. Moreover, in many benign arrhythmias (e.g. premature beats), a number of general factors may influence and modulate the frequency and severity of the symptoms. In this context, changes in lifestyle (e.g. restraining adrenergic substances such as caffeine or alcohol-containing beverages) or non-cardiologic therapies (e.g. anxiolytic drugs or psychiatric counselling) may be useful to control symptoms and should be considered. At times, reassurance on the benign nature of the disorder can markedly reduce symptoms.

Clearly, patients with palpitations will benefit from the same preventive measures recommended to the general population and to patients with cardiovascular disease. Especially in patients with ventricular ectopy and possibly also in patients with atrial ectopic beats, although scientific evidence is lacking, intensified reduction of cardiovascular risk factors may be warranted. This may comprise, among others, smoking cessation, therapy of dyslipidemia, management of hypertension, heart failure, and diabetes mellitus, to name but a few. Moderate exercise is a healthy habit that helps in controlling cardiovascular risk factors. On the other hand, high-intensity endurance sport practice has been related to an increased risk of atrial fibrillation.

It is beyond the scope of this Answer to discuss in depth the specific therapy in all arrhythmic conditions causing palpitations. In this regard, I would refer you to an electrophysiologist and let him take matters in his hands and treat these palpitations accordingly. MVP can be a trigger to it.
Here are some basic guidelines for treating palpitations.
1)Therapy should be directed towards the aetiological cause.
2)Patients should be reassured in case of a benign cause.
3)Use of adrenergic substances such as caffeine or alcohol-containing beverages should be restrained.
4)Good control of cardiovascular risk factors, specifically of hypertension, should be ensured.
5)If there is a recent stressful life-event, psychiatric counselling may be of help.
6)In patients with symptoms of anxiety and depression, a specific therapy is warranted.
7)If a specific arrhythmia is found, the appropriate therapy may be antiarrhythmic drugs, ablation, or even an implantable defibrillator.
8)In the case that arrhythmias are found to be related to systemic diseases or to the use of pro-arrhythmic drugs, therapy, of course, must aim to remove the underlying conditions.
I hope it helps. May you always find something witty in my replies and get an idea of a better management under the license of self education but not self treatment.
Take good care my favourite couple patient. God bless you both.
Regards
S Khan

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