Myasthenia gravis--a rare presentation with tongue atrophy and fasciculation

Atypical Bulbar Myasthenia Gravis in an Elderly Male Unmasked by Levofloxacin: A Diagnostic Challenge

Background

Myasthenia gravis (MG) is an autoimmune neuromuscular disorder that typically presents with ocular symptoms. Isolated bulbar symptoms, such as dysphagia and dysarthria, are rare, and most commonly seen in men with late-onset MG. We report one such rare case of MG in an 82-year-old male presenting with progressive bulbar weakness, seemingly triggered by levofloxacin use.

Case Report

An 82-year-old male with multiple comorbidities presented with progressive weakness, dysphagia, and drooling following levofloxacin therapy. Examination revealed neck drop, weak lower facial muscles, and dysarthria. Initial neuroimaging and labs were inconclusive. Neurology initiated pyridostigmine with rapid improvement. Elevated acetylcholine receptor antibodies confirmed MG. He was started on efgartigimod alfa in the outpatient setting with improvement in MG composite scores.

Conclusions

Atypical bulbar MG can mimic other neurologic disorders and is prone to delayed diagnosis, especially in the elderly. Clinicians should maintain a high index of suspicion, particularly when symptoms worsen after medication exposures like fluoroquinolones. Early diagnosis and appropriate treatment can significantly improve outcomes and quality of life.

LEARNING POINTS

Levofloxacin can exacerbate or unmask myasthenia gravis.

Atypical bulbar myasthenia gravis in an elderly male unmasked by levofloxacin: a diagnostic challenge

Background: Myasthenia gravis (MG) is an autoimmune neuromuscular disorder that typically presents with ocular symptoms. Isolated bulbar symptoms, such as dysphagia and dysarthria, are rare, and most commonly seen in men with late-onset MG. We report one such rare case of MG in an 82-year-old male presenting with progressive bulbar weakness, seemingly triggered by levofloxacin use. Case Report: An 82-year-old male with multiple comorbidities presented with progressive weakness, dysphagia, and drooling following levofloxacin therapy. Examination revealed neck drop, weak lower facial muscles, and dysarthria. Initial neuroimaging and labs were inconclusive. Neurology initiated pyridostigmine with rapid improvement. Elevated acetylcholine receptor antibodies confirmed MG. He was started on efgartigimod alfa in the outpatient setting with improvement in MG composite scores. Conclusions: Atypical bulbar MG can mimic other neurologic disorders and is prone to delayed diagnosis, especially in the elderly. Clinicians should maintain a high index of suspicion, particularly when symptoms worsen after medication exposures like fluoroquinolones. Early diagnosis and appropriate treatment can significantly improve outcomes and quality of life.

Predominant Intractable Nausea in the Diagnosis of Bulbar Myasthenia Gravis: A Case Study and Review of Literature

Gastrointestinal (GI)-predominant myasthenia gravis (MG) is rare and presents a complex clinical scenario. We report the case of a 73-year-old female with dysphagia and intractable nausea found to have bulbar MG. Her symptoms persisted despite conventional MG management with plasma exchange therapy and anticholinergics. We review existing literature and discuss the clinical manifestations, diagnosis, and treatment of bulbar MG. This case highlights the need for novel MG treatment modalities in patients like ours with anomalous, GI-predominant MG who might not respond to conventional management.

Thymoma associated myasthenia gravis with atypical presentation of lipomatous tongue atrophy: a case report

A 28-year-old female patient came to the outpatient dental clinic for multiple teeth extractions and full mouth rehabilitation suffer from myasthenia gravis (MG) primary presentation as tongue atrophy and facial muscles weakness and the symptoms became worries, the patient unable to speak as well and change her voice and complaining of dysphagia and dysarthria. Oral symptoms, treatment schedule and protocol, the selection, prescription and impacts of medications, and prevention of myasthenic crisis are all important; aspects should be considered by dentists and oral health care providers. Weakness of facial and oropharyngeal muscle is considered very popular at disease onset and therefore oral health providers are often the first medical professionals to observe these patients. Myasthenic patients seek particular approach and consultation in order to ensure ideal and proper dental management.

Tongue fasciculations with denervation pattern in osmotic demyelination syndrome: a case report of diagnostic dilemma

Background

The pathogenesis of osmotic demyelination syndrome is not completely understood and usually occurs with severe and prolonged hyponatremia, particularly with rapid correction. It can occur even in normonatremic patients, especially who have risk factors like alcoholism, malnutrition and liver disease. Bilateral tongue fasciculations with denervation pattern in electromyogram is a manifestation of damage to the hypoglossal nucleus or hypoglossal nerves. Tongue fasciculations were reported rarely in some cases of osmotic demyelination syndrome, but the exact mechanism is not explained.

Case presentation

A 32-year-old Sri Lankan male, with a history of daily alcohol consumption and binge drinking, presented with progressive difficulty in walking, dysphagia, dysarthria and drooling of saliva and alteration of consciousness. On examination he was akinetic and rigid resembling Parkinsonism with a positive Babinski sign. Clinical features were diagnostic of osmotic demyelination syndrome and MRI showed abnormal signal intensity within the central pons and basal ganglia. He also had tongue fasciculations. The electromyogram showed denervation pattern in the tongue with normal findings in the limbs. Medulla and bilateral hypoglossal nerves were normal in MRI.

Conclusion

We were unable to explain the exact mechanism for the denervation of the tongue, which resulted in fasciculations in this chronic alcoholic patient who developed osmotic demyelination syndrome. The hypoglossal nuclei are located in the dorsal medulla and radiologically undetected myelinolysis of the medulla is a possibility. Hypoglossal nerve damage caused by methanol or other toxic substances that can contaminate regular ethyl alcohol is another possibility, as it is known to cause neurological and radiological features similar to osmotic demyelination syndrome with long-term exposure. So these toxic substances might play a role in chronic alcoholic patients with central pontine myelinolysis.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3287-8) contains supplementary material, which is available to authorized users.

Myasthenia gravis masquerading as dysphagia: unveiled by magnesium infusion

Myasthenia gravis (MG) is a neuromuscular disorder that typically affects the ocular, bulbar, neck, proximal limbs and respiratory muscles. Dysphagia can occasionally be the only presenting symptom leading to extensive but ultimately futile gastrointestinal workup. Delay in diagnosis and use of certain pharmacological agents in the interim can lead to a myasthenic crisis, which though diagnostic is life threatening. We document a case of dysphagia as the only symptom of myasthenia, diagnosed after a magnesium infusion precipitated myasthenic crisis. A 70-year-old Caucasian woman who had had progressive dysphagia for 2 years, for which multiple oesophageal dilations were performed. During a hosptalisation for further gastrointestinal workup, she went into myasthenic crisis (respiratory failure) after receiving magnesium replacement. She required ventilatory support and received five plasma exchange (PLEX) treatments after myasthenia was confirmed by the detection of high antiacetylcholine receptor antibody. Though her symptoms improved, she had a prolonged hospital stay (25 days) and required 18 days of mechanical ventilation. This underscores the morbidity associated with a delay in diagnosis of this condition. This case report suggests that neuromuscular causes should be considered early in elderly patients presenting with dysphagia. Timely diagnosis, initiation of management and avoidance of drugs that affect neuromuscular transmission may help reduce the morbidity and mortality associated with myasthenic crisis.

Electrodiagnosis in persons with amyotrophic lateral sclerosis

Electrophysiology remains an important tool in the evaluation of patients presenting with signs and symptoms of motor neuron disease. The electrodiagnostic study should include peripheral nerve conduction studies and needle electromyography to both exclude treatable disease and gather evidence regarding a diagnosis of amyotrophic lateral sclerosis (ALS). The recent changes in the revised El Escorial criteria, recommended by the Awaji-shima consensus group, have increased the diagnostic significance of fasciculation potentials to equal that of fibrillation and positive sharp-wave potentials in the needle electromyography examination of patients suspected of having ALS. In addition, electrophysiologic evidence is now considered equivalent to clinical signs and symptoms in reaching a diagnostic certainty of ALS. These changes, strategies for the design, and implementation of an effective electrodiagnostic evaluation, in addition to electrophysiologic techniques and their relationship to the evaluation of a patient with ALS, are reviewed and discussed.

A rare cause of Dysphagia: a case report

Dysphagia is a common clinical symptom for an ENT surgeon in his clinic, evaluation of which may not be a great challenge. The objective of this article is to report a rare cause of dysphagia which may be difficult to diagnose unless specifically thought of. This is a report of a case of dysphagia secondary to myasthenia gravis seen in a young lady along with tongue fasciculation in an early onset case unlike the ones reported in the literature where the patients are elderly and more often males in the late phase of the disease. At times, dysphagia may be seen secondary to some rare causes and may mislead the doctor. A carefully taken history and methodical clinical examination will avoid unnecessary invasive procedures and delay in the diagnosis.

Inflammatory Myopathy with Severe Tongue Atrophy in Pembroke Welsh Corgi Dogs

A disease characterized by tongue and facial muscle atrophy has been recognized sporadically among Pembroke Welsh Corgi (PWC) dogs in Japan. The present study describes the pathologic findings of this canine syndrome. Histopathologic examinations were performed in 2 dogs, including a case of muscular biopsy. Identification and characterization of autoantibodies were attempted by fluorescent antibody test (FAT) and Western blot (WB) by using sera from 7 PWC dogs with typical clinical features, 6 PWC dogs with other clinical signs, and 2 from other breeds with polymyositis. Clinically, the 7 affected PWC dogs exhibited dysphagia with severe tongue atrophy, facial muscular atrophy, and occasional walking difficulty. Histopathologic examinations of the 2 dogs with clinical symptoms revealed moderate to severe inflammatory lesions characterized by lymphohistiocytic infiltration and muscular atrophy in the tongue and/or femoral muscles. The tongue lesions were very severe and accompanied by diffuse fatty infiltration. There were no major lesions in the nervous tissues examined. By FAT, an autoantibody against the cross striation of skeletal muscle was detected in sera from 5 affected PWC dogs. By using WB analysis, the autoantibodies recognized a 42-kDa molecule in striated muscle but not in the nervous tissues. All of the findings indicated that the unique disease of PWC dogs might be generalized inflammatory myopathy, whereas the detailed etiology concerning the dominant involvement of tongue muscles and the role of the autoantibody in the canine disease remain to be clarified.