What Can Worsen Myasthenia Gravis?

Myasthenia Gravis can cause daily, and sometimes hourly changes. While varying levels of fatigue and muscular flaccidity is normal, especially towards the end of the day, there is distinction between these occurrences and exacerbation. Many patients will find that they are fairly stable one day and struggling for the next several. These continual fluctuations can be precipitated by the nature of the immune system and the disease itself or other outside influences (listed below).   
Deviation of baseline neurological function can lead to acute exacerbation that, if not dealt with correctly, has the potential lead to crisis.
Changing, or removing, the offending exacerbator usually allows for a return to baseline function without further intervention, but the patient must be carefully monitored as Myasthenia Gravis is clinically noted to change without warning.  Exacerbation can manifest with rather sudden swings in patient presentation. The initial offenders to be assessed are poor therapeutic control, changes in medication regimen and illness/infection. Commonly seen is insufficient IVIG dosage, inadequate acetylcholinesterase inhibition, contraindicated drugs or excessive steroid therapy.

Common exacerbtors of Myasthenia Gravis are (but not limited to): 

• imbalanced serum levels of calcium and potassium
• hypo/hyper thyroidism
• menstrual cycle (changes in hormones alters acetycholine production)
• lack of sleep
• temperature extremes: heat is a rapid accelerator of systemic flaccidity and can quickly cause a patient to experience respiratory distress or crisis. Each patient will have varying tolerance levels of heat. (extreme temperatures change nerve transmission)
• hot beverages and foods
• contraindicated drug not tolerated by the patient
• allergies
• poor hydration
• lack of appropriate nutrition
• inconsistent therapeutic treatment
• underlying co-morbidities or additional autoimmune conditions that are not stable
• stress 
• infection
• fever
• cold/flu
• surgery recovery/complications
• deet
• lawn chemicals/pesticides
• dietary magnesium (a macro-nutrient, magnesium is essential for overall health. However, in Myasthenia Gravis, moderate to large amounts in dietary or supplemental form can quickly increase systemic flaccidity by inhibiting acetylcholine pre-synaptically and post-synaptically, behaving in a similar way to the attacking antibodies. Magnesium supplementation should be given only under careful supervision by a skilled doctor and when the patient is deficient. Even under necessary supplementation, it is common to see rapid, acute exacerbation. Infusion with deficiency should be monitored with great caution)