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Case 213

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49 years old female patient seeks medical care with the story of diplopia and left eye ptosis in the previous three weeks. She also reports difficulty to walk, having many times fallen over, especially during night time. There is also dysarthria, dysphagia and difficulty with chewing. Upon examination, she presents isochoric and photo reactive pupils and general paresis (4/5). Electromyoneurography and Computed tomography (CT ) of the chest were requested.

Based on the history and the image, one can conclude that the most likely diagnosis is:

a) Amyotrophic Lateral Sclerosis

25%

b) Lambert-Eaton Myasthenic Syndrome

25%

c) Botulism

25%

d) Myasthenia gravis

25%
   

Image analysis

 

 

 

 

 

Images 1, 2 and 3: High resolution chest/mediastinum CT: oval , circumscribed , homogeneous lesion with soft tissue density , located in the anterior- superior mediastinum , measuring about 3.2 x 2.4 x 2.2 cm (W x T x AP ) . A slight densification of the surrounding adipose plans overlaps it.

Unequivocal signs and invasion of vascular structures are not identified. There are no signs of axial lymph node enlargement, mediastinal nor hilar. The possibility of a thymoma should be considered.

Highlights

- Myasthenia gravis is an autoimmune disease mediated by antibodies created against acetylcholine receptors in the motor end plate;

- It is characterized by fluctuating weakness of eye, bulbar, appendicular and breathing muscles that worsen throughout the day and according to the performance of physical exercises;

- The diagnosis should be confirmed by serological tests and electrophysiological studies;

- 15 % of patients have tumors in the thymus and is essential to carry out a chest CT;

- The treatment is individualized , taking into consideration the presentation of the disease , age and severity.

 References

- Bird SJ. Differencial diagnosis of myasthenia gravis. Shefner JM, editor. UpToDate; 2015.Available in : http://www.uptodate.com/contents/differential-diagnosis-of-myasthenia-gravis?source=search_result&search=miastenia+gravis&selectedTitle=7~150

- Bird SJ. Clinical manifestations of myasthenia gravis. Shefner JM, editor. UpToDate; 2015. Available in: http://www.uptodate.com/contents/clinical-manifestations-of-myasthenia-gravis?source=search_result&search=miastenia+gravis&selectedTitle=3~150

- Bird SJ. Treatment of myasthenia gravis. Shefner JM, editor. UpToDate; 2015. Available in: http://www.uptodate.com/contents/treatment-of-myasthenia-gravis?source=search_result&search=miastenia+gravis&selectedTitle=4~150

- Ministério da Saúde. Miastenia Gravis. Protocolo Clínico e Diretrizes Terapêuticas. 2010. Available in :http://portalsaude.saude.gov.br/images/pdf/2014/abril/02/pcdt-miastenia-gravis-retificado-livro-2010.pdf

Author

Raíra Cesar e Cezar, 5th year medical student at UFMG.

E-mail: rairacezar[at]gmail.com

Supervisor

Dr. Breno Franco Silveira Fernandes, neurologist, assistant doctor at Hospital das Clínicas da UFMG

E-mail: brenofranco[at]gmail.com

Reviewers

Fellype Borges, Luanna Monteiro, Fernando Bottega, André Guimarães, Cairo Mendes and Prof. Viviane Parisotto

Translated by

Rafael Fusaro Aguiar Oliveira, 4th year medical student at UFMG.

E-mail: rafusaro[at]hotmail.com

 

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