Patient Presentation:

A.F., a 55 year old male presents to the ER with multiple complaints, including ptosis, dysarthria, shortness of breath, and muscle weakness of his lower extremities.  BP is 149/88, HR is 92, O2-sats are 93% on room air, RR is 19, and temperature is 99.3.    The ptosis has been a recurrent problem for the last two years and has not been resolved after two visits to the optometrist.  Within the past several months he reports increased muscle weakness and difficulty chewing and swallowing properly.  Last month he was treated in the ER for aspiration pneumonia and discharged.  Patient reports that he has recently been under a lot of stress.    

Differential list:

Stroke

Multiple Sclerosis

Brain tumor

Pneumonia

Myasthenia Gravis

Diagnosis: 

In the ER a chest x-ray was performed that revealed bilateral infiltrates.  CBC showed an elevated WBC of 13,000.   BMP revealed mild hyponatremia with a sodium level of 130.  All other electrolytes were within normal limits.  CT scan does not reveal infarct or hemorrhage.  MRI is ordered which is also negative.  EKG is normal sinus rhythm.  500 mg of IV Levaquin is started in the ER to treat the pneumonia along with a bolus of 0.9% Normal Saline.  Patient is admitted from ER for pneumonia and a neurology referral is placed.  Neurology sees the patient after he is admitted to the hospital and orders an acetylcholine receptor antibody test.  Elevated serum antibodies to the acetylcholine receptors confirm a diagnosis of Myasthenia Gravis. 

Treatment:

The neurologist treats the patient with Pyridostigmine 60 mg three times a day and Prednisone 5 mg everyday. 

Outcome:

The prognosis for those with Myasthenia Gravis is good and it is possible that symptoms may go into remission with medication therapy.  It is important to be aware that muscle weakness can cause respiratory distress and needs to be attended to urgently.