MYASTHENIA GRAVIS PRESENTS AS BULBAR PALSY WITHOUT THYMOMA
Abstract
Myasthenia gravis is the most common neuromuscular junction disorder associated with autoimmune diseases, although around 10-15% of patients have no detectable antibodies, and 85% of patients have antibodies. Bulbar symptoms are not commonly present in the early stages, although they often occur as the disease advances. We report 2 unique cases of myasthenia gravis manifesting as isolated bulbar palsy. The first case involves a 56-year-old male patient with a history of diabetes mellitus presenting with the early onset of bulbar palsy in the course of myasthenia gravis. The second case features a patient diagnosed with rheumatoid arthritis, presenting symptoms of speech and swallowing difficulties alongside joint pain, without the usual muscle weakness associated with myasthenia gravis. Prompt assessment is emphasized in this case study, even when faced with challenges in diagnosing MG due to the lack of general weakness with ocular symptoms, which ultimately increases the patient's chances of survival.
Keywords
Downloads
References
- Hehir MK, Silvestri NJ. Generalized Myasthenia Gravis: Classification, Clinical Presentation, Natural History, and Epidemiology. Neurologic Clinics. 2018; 36(2):253-60. https://doi.org/10.1016/j.ncl.2018.01.002
- Priola AM, Priola SM. Imaging of thymus in myasthenia gravis: From thymic hyperplasia to thymic tumor. Clinical Radiology. 2014; 69(5): 230-45 https://doi.org/10.1016/j.crad.2014.01.005
- Gilhus NE, Owe JF, Hoff JM, Romi F, Skeie GO, Aarli JA. Myasthenia gravis: a review of available treatment approaches. Autoimmune Diseases. vol. 2011, Article ID 847393, 6 pages, 2011. https://doi.org/10.4061/2011/847393
- Gilhus NE, Tzartos S, Evoli A, Palace J, Burns TM, Verschuuren JJGM. Myasthenia gravis. Nature Reviews Disease Primers. 2019; 5(1). https://doi.org/10.1038/s41572-019-0079-y
- Gwathmey K, Burns T. Myasthenia Gravis. Seminars in Neurology. 2015; 35(04):327-39. https://doi.org/10.1055/s-0035-1558975
- Basiri K, Ansari B, Okhovat AA. Life-threatening misdiagnosis of bulbar onset myasthenia gravis as a motor neuron disease: How much can one rely on exaggerated deep tendon reflexes. Advanced Biomedical Research. 2015; 4(1):58. https://doi.org/10.4103/2277-9175.151874
- Herr KJ, Shen S-P, Liu Y, Yang C-C and Tang C-H. The growing burden of generalized myasthenia gravis: a population-based retrospective cohort study in Taiwan. Frontiers in Neurology. 2023; 14:1203679. https://doi.org/10.3389/fneur.2023.1203679
- Patrick J, Lindstrom J: Autoimmune response to acetylcholine receptor. Science. 1973; 180:871-2. https://www.doi.org/10.1126/science.180.4088.871
- McConville J, Farrugia ME, Beeson D, Kishore U, Metcalfe R, Newsom-Davis J, et al. Detection and characterization of MuSK antibodies in seronegative myasthenia gravis. Annals of Neurology. 2004; 55:580-4. https://doi.org/10.1002/ana.20061
- Pevzner A, Schoser B, Peters K, Cosma N-C, Karakatsani A, Schalke B, et al. Anti-LRP4 autoantibodies in AChR- and MuSK-antibody-negative myasthenia gravis. Journal of Neurology. 2012; 259:427-35. https://doi.org/10.1007/s00415-011-6194-7
- Zhang B, Shen C, Bealmear B, Ragheb S, Xiong W-C, Lewis RA, et al. Autoantibodies to agrin in myasthenia gravis patients. PLoS One. 2014, 9(3): e91816. https://doi.org/10.1371/journal.pone.0091816
- Wendell LC, Levine JM. Myasthenic Crisis. Neurohospitalist. 2011; 1(1):16-22. https://doi.org/10.1177/1941875210382918
- Tai H, Cui L, Guan Y, Liu M, Li X, Huang Y, et al. Amyotrophic Lateral Sclerosis and Myasthenia Gravis Overlap Syndrome: A Review of Two Cases and the Associated Literature. Frontiers in Neurology. 2017; 8:218. https://doi.org/10.3389/fneur.2017.00218
- Remijn-Nelissen L, Verschuuren JJ, Tannemaat MR. The effectiveness and side effects of pyridostigmine in the treatment of myasthenia gravis: a cross-sectional study. Neuromuscular Disorders. 2022, 32:790-9. https://doi:10.7759/cureus.50017
- Skeie GO, Apostolski S, Evoli A, Gilhus NE, Illa I, Harms L, et al. Guidelines for treatment of autoimmune neuromuscular transmission disorders. European Journal of Neurology. 2010, 17:893-902. https://doi.org/10.1111/j.1468-1331.2010.03019.x