As clinicians we can become complacent to the trepidation that some patients face. Can myasthenia gravis be diagnosed with the ice pack test. Ice pack test ptosis improves with ice pack application. Rns test in the facial nerve revealed a definite improvement in the decremental response. Ice pack test to improve strength of the eyelid what are the treatment options. Mg does not yet have a cure, but effective treatments are available.
In myasthenia gravis mg, ocular symptoms occur in almost all patients i n s o m e p o i n t d u r i n g c o u r s e o f disease. Life threatening myasthenia crisis respiratory failure can be seen before diagnosis or due to inadequate drug therapy or tolerance. Citeseerx document details isaac councill, lee giles, pradeep teregowda. Myasthenia gravis is an autoimmune disease affecting acetylcholine receptors. Citeseerx the ice test for diagnosing myasthenia gravis. The ice pack test may be helpful in establishing that ptosis is due to ocular myasthenia gravis, since cold improves neuromuscular transmission.
The diagnosis of the less obvious pure ocular form of the disorder can be greatly improved with the ice pack test as there are often no other. From this we conclude that the icepack test produces a clinical and electrophysiological improvement in myasthenia gravis. Myasthenia gravis is an autoimmune disease of the neuromuscular junction that presents clinically as fluctuating weakness of skeletal muscles, as of the ocular region myasthenia ocular. What is the role of the ice pack test in the evaluation of. The response is positive when there is improvement of the diplopia or. The use of the ice pack test in myasthenia gravis europe. The ice pack test is cheap, safe, and very quick to perform as it can be carried out at the bedside in approximately 35 minutes. The place of the ice pack test in the diagnosis of.
The ice pack test ie, placing ice over the lid has gained interest among ophthalmologists for assessing improvement in ptosis and diplopia in ocular mg. Ice pack test for myasthenia gravis, journal of neurology. Abstract there are many tests for diagnosis of myasthenia gravis including tensilon test and ice test. The findings of ptosis, extraocular muscle weakness, dysphagia, limb fatigability, supportive ice pack test and positive antititin antibodies were considered diagnostic of mg. Ice pack testan useful bedside test to diagnose myasthenia gravis. A common symptom of myasthenia gravis is eyelid ptosis. Improvement in ptosis and ocular motility noticed after the placement of ice pack for 2minutes over the closed lids in a patient with myasthenia gravis. Diagnosis of myasthenia gravis is difficult, especially when the disease is restricted to ocular muscles. She had positive result on ice pack test and an excellent response to. The ice pack test demonstrated high specificity and an acceptable sensitivity in the differential diagnosis of myasthenic diplopia. To compare the ice test with tensilon test in sub jects with myasthenic and nonmyasthenic ptosis a process research study was designed.
Ice test in the diagnosis of myasthenic ptosis gupta m. Myasthenia gravis was suspected, and the icepack test was performed with the placement of an instant cold pack over the left eye panel b. The ice pack test may be helpful in establishing that ptosis is due to ocular. Edrophonium or neostigmine acetylcholinesterase inhibitor improves muscle strength limited use in testing as may worsen weakness in other nmj disorders or cholinergic crisis leading to respiratory failure. The ice pack test in the differential diagnosis of. Positive in 8090% of generalized mg and 4055% in ocular mg. The use of the ice pack test in myasthenia gravis ncbi. View enhanced pdf access article on wiley online library html view download pdf for offline viewing. Patients with nonmyasthenic ptosis do not improve in the ice test 2,3,5,6,8. Based on this evidence, orbital cooling ice pack test has been developed as a simple, safe and reliable procedure for the diagnosis of ocular myasthenia 17,18. Achr antibody testing is the most specific test, although 15% can have false negatives. The ice pack test in the differential diagnosis of myasthenic diplopia.
Read ice pack test for myasthenia gravis, journal of neurology on deepdyve, the largest online rental service for scholarly research with thousands of academic publications available at. The ice pack test for diagnosing myasthenia gravis ophthalmology. The most commonly affected muscles are those of the eyes, face, and swallowing. Ice pack test in the diagnosis of myasthenia gravis scielo. Improvement following ice supports a diagnosis of myasthenia gravis see video below. Accuracy of the ice test in the diagnosis of myasthenic ptosis. Pdf ice pack test in the diagnosis of myasthenia gravis. Pdf hospital can be a very frightening place for patients. The result of the test speaks for itself, regardless of how it affects the upper eyelid position of a paretic levator palpebrae. The test was used in this case with striking results figures 1 and 2. Bedsides clinical tests that can be done are tensilon test and ice pack test.
A cautionary note andrew j larner, dafydd j thomas summary the ice pack test may be helpful in establishing that ptosis is due to ocular myasthenia gravis, since cold improves neuromuscular transmission. Autoimmune mg and diagnostic tests myasthenia gravis. It is a wellknown observation that myasthenic ptosis improves with cold and based on this, the ice pack test has been used as a tool in its differential diagnosis. With the use of an ice pack test, a bedside test for improvement of ptosis, the patient was diagnosed with myasthenic ptosis preventing. Bedside tests the ice pack test and, historically, the edrophonium test are sensitive, but they have major limitations due to concerns about excess falsepositive results. In all mg patients n 23, the mean change in palpebral aperture distance due to the ice test was 1. In the evaluation of ptosis, the ice pack test is a simple, quick, bedside.
It can take time to find the right combination of treatments for each person. Diagnosis of myasthenia gravis is often challenging especially in an intubated patient. Pdf validation of the ice pack test in ophthalmoparesis. Ice pack test in the diagnosis of myasthenia gravis. However, the role of the test in determining whether diplopia is of myasthenic origin has yet to be established. In spite of a partial response to the treatment, the symptoms. Ice pack test improvement of ptosis improvement of ptosis. Patients with a positive response in the ice test but with negative edrophonium test.
Diagnosis of myasthenia gravis in young infants in challenging, as clinical features are often nonspecific and investigations are nonconfirmatory. The most common the edrophonium test carries a risk of serious cardiac adverse reactions and. Myasthenia gravis and concurrent myositis following pdl1. Eight of 10 patients with myasthenia gravis improved, whereas none of the controls improved. Often, the edrophonium test is negative, particularly in ocular myasthenia gravis. The ice test may also be useful in the diagnosis of myasthenia gravis,even in patients in whom edrophonium testing is negative.
However, the role of the test in determining whether. Evaluating the temperature effects of ice and heat tests. It can result in double vision, drooping eyelids, trouble talking, and trouble walking. Ocular myasthenia gravis mg, in men, without progression to generalised disease and crisis in the absence of treatment for 10 years is rare, as most of the patients usually progress to generalised myasthenia in 2 years as evident in most of the studies. We applied ice packs to the eye in 10 myasthenic patients and 7 disease controls. Ice pack tests ice pack tests are examinations performed by specialists to evaluate strength and recovery responses that could be consistent with an mg diagnosis. In up to 20 percent of people symptoms may improve or disappear for up to. Data from this series suggest that a partial rather than a complete response to the ice pack test may be expected for myasthenic diplopia. The patients systemic features, proximal limb weakness, raised ck, positive pmscl75 antibody and myopathic electromyography led to a concurrent diagnosis of myositis. Pdf ice pack test for ophthalmoparesis in myasthenia.
Diagnosis ice test muscles in mg function better in a lower temperature decreased acetylcholinesterase activity increased depolarizing effect of acetylcholine at motor endplates applying ice pack on the eyelid during closing for 2. This study was performed in patients complaining of acquired ptosis in the. A complete diagnostic workup was ordered and patients were followed up for a minimum of 6 months before diagnosis of myasthenia gravis was. Place ice pack over patients eye that is affected with ptosis or ophthalmoparesis for two minutes. The results of the ice, rest, and heat tests are summarised in table 1. In the severe form of illness, it can present as myasthenia crisis where there is severe bulbar and respiratory weakness that requires mechanical ventilation. The ice pack test in a young infant with myasthenia gravis. Myasthenia gravis was suspected, and an icepack test was performed with an instant cold pack over the left eye.
We report a 2month infant with poor suck, hypotonia and ptosis. The ice pack test seems to be both sensitive and specific when compared with the edrophonium test 8,19, although there are no randomized and controlled studies to validate it. Sluggish turnaround time limits the ability of this test to guide immediate treatment decisions. All three patients showed an unequivocal improvement in ptosis on the side where an ice pack was placed. Orbital cooling with an ice pack was described as a test for ocular myasthenia in 1979 and has been proven to be valid for myasthenic ptosis.
Pdf the use of the ice pack test in myasthenia gravis. This test is easily performed in the oce and is accomplished by placing an ice pack over an aected eye for 2 minutes. The place of the ice pack test in the diagnosis of myasthenia gravis. Those affected often have a large thymus or develop a thymoma. Although, not studied in a large cohort, case reports suggest the ice pack test may help with the diagnosis. However, the role of the test in determining whether diplopia is of myasthenic. Ice pack test should improve symptoms temporarily usually ptosis.
The ice pack test is cheap, safe, and very quick to perform as it can be carried. It consists of the application of an ice pack on the patient symptomatic eye for 3 to 5 minutes. Myasthenia gravis mg is a longterm neuromuscular disease that leads to varying degrees of skeletal muscle weakness. Diagnosing myasthenia gravis with an ice pack nejm. The ice pack test is a useful bedside test that can aid in the differentiation of mg from other conditions. Ice pack test for ophthalmoparesis showed a sensitivity of 83%, specificity 100%, positive predictive value ppv of 100% and negative predictive value npv of 80% in the diagnosis of myasthenia.
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