Accepted Manuscript Myasthenia Gravis Presenting with Dysphagia in an Elderly Male: A Case Report Ellen Breen , M.D. Lauren Bleich , M.D., M.P.H Caroline Loeser , M.D PII:
S0002-9343(14)00464-1
DOI:
10.1016/j.amjmed.2014.05.028
Reference:
AJM 12547
To appear in:
The American Journal of Medicine
Received Date: 12 May 2014 Revised Date:
22 May 2014
Accepted Date: 22 May 2014
Please cite this article as: Breen E, Bleich L, Loeser C, Myasthenia Gravis Presenting with Dysphagia in an Elderly Male: A Case Report, The American Journal of Medicine (2014), doi: 10.1016/ j.amjmed.2014.05.028. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Myasthenia gravis presenting with dysphagia
ACCEPTED MANUSCRIPT Myasthenia Gravis Presenting with Dysphagia in an Elderly Male: A Case Report
*
Saba University School of Medicine, Saba, Netherland Antilles
¶
RI PT
Ellen Breen, M.D.*, Lauren Bleich, M.D., M.P.H ¶, Caroline Loeser, M.D. ¶
Division of Gastroenterology, Department of Medicine, Bridgeport Hospital-Yale
SC
New Haven Health, Bridgeport, CT
Running head: Myasthenia gravis presenting with dysphagia
M AN U
Key words: Myasthenia Gravis, Dysphagia,
Corresponding Author:
EP
TE D
Ellen Breen, M.D. Saba University School of Medicine c/o R3 Education Inc. 27 Jackson Road, Suite 301 Devens, Massachusetts, 01434, United States Phone: (203) 895 2488 E-mail: [email protected]
AC C
The authors of this manuscript have no conflicts of interest to disclose. All authors of this manuscript had access to the data and a role in writing the manuscript; article type; and key words.
1
Myasthenia gravis presenting with dysphagia
ACCEPTED MANUSCRIPT Myasthenia Gravis Presenting with Dysphagia in an Elderly Male: A Case Report
*Saba University School of Medicine, Saba, Netherland Antilles
RI PT
Ellen Breen, M.D.*, Lauren Bleich, M.D., M.P.H ¶, Caroline Loeser, M.D. ¶
¶ Division of Gastroenterology, Department of Medicine, Bridgeport Hospital-Yale
SC
New Haven Health, Bridgeport, CT
M AN U
To the Editor:
Myasthenia gravis is a well characterized autoimmune disorder caused by an antibody mediated attack of the acetylcholine receptors in the post synaptic membrane of the neuromuscular junction. Initial presentation is typically characterized by progressive
TE D
muscle fatigability, most commonly targeting the ocular system, and resulting in ptosis and diplopia. Bulbar manifestations, such as dysarthria and dysphagia, are more commonly seen in, although not limited to, elderly male populations. Signs and
EP
symptoms of bulbar weakness, rather than ocular manifestations, have been reported to occur as the presenting symptoms of myasthenia; however, this is exceedingly less
AC C
common, accounting for only six percent of cases.1 We hereby describe the case of a 64-year-old male, with past medical history of hypertension, and hypothyroidism secondary to Hashimoto’s thyroiditis, who presented with a primary complaint of progressive dysphagia to both solid and liquids. Additional signs and symptoms included dysarthria, upper and lower extremity weakness and a 40 pound weight loss over the previous 2 months. His family noted that he experienced intermittent left eye droop. Physical examination was significant for left eyelid ptosis and a miotic left pupil. Muscle strength was 1/5 2
Myasthenia gravis presenting with dysphagia
ACCEPTED MANUSCRIPT in the upper and lower extremities bilaterally. Sensation was intact throughout. Shortly after admission to the hospital, the patient required intubation secondary to respiratory failure due to exhaustion of the respiratory muscles. Upper endoscopy findings included a small hiatal hernia but no obstructive lesion was
RI PT
seen. Barium swallow demonstrated reduced lingual strength, severely delayed
swallow reflex, and weak bolus propulsion. Electromyographic evaluation was
suggestive of a myopathic process. Acetylcholine receptor binding antibody (AChR-
SC
Ab) was >75nmol/L (normal
S0002-9343(14)00464-1
DOI:
10.1016/j.amjmed.2014.05.028
Reference:
AJM 12547
To appear in:
The American Journal of Medicine
Received Date: 12 May 2014 Revised Date:
22 May 2014
Accepted Date: 22 May 2014
Please cite this article as: Breen E, Bleich L, Loeser C, Myasthenia Gravis Presenting with Dysphagia in an Elderly Male: A Case Report, The American Journal of Medicine (2014), doi: 10.1016/ j.amjmed.2014.05.028. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Myasthenia gravis presenting with dysphagia
ACCEPTED MANUSCRIPT Myasthenia Gravis Presenting with Dysphagia in an Elderly Male: A Case Report
*
Saba University School of Medicine, Saba, Netherland Antilles
¶
RI PT
Ellen Breen, M.D.*, Lauren Bleich, M.D., M.P.H ¶, Caroline Loeser, M.D. ¶
Division of Gastroenterology, Department of Medicine, Bridgeport Hospital-Yale
SC
New Haven Health, Bridgeport, CT
Running head: Myasthenia gravis presenting with dysphagia
M AN U
Key words: Myasthenia Gravis, Dysphagia,
Corresponding Author:
EP
TE D
Ellen Breen, M.D. Saba University School of Medicine c/o R3 Education Inc. 27 Jackson Road, Suite 301 Devens, Massachusetts, 01434, United States Phone: (203) 895 2488 E-mail: [email protected]
AC C
The authors of this manuscript have no conflicts of interest to disclose. All authors of this manuscript had access to the data and a role in writing the manuscript; article type; and key words.
1
Myasthenia gravis presenting with dysphagia
ACCEPTED MANUSCRIPT Myasthenia Gravis Presenting with Dysphagia in an Elderly Male: A Case Report
*Saba University School of Medicine, Saba, Netherland Antilles
RI PT
Ellen Breen, M.D.*, Lauren Bleich, M.D., M.P.H ¶, Caroline Loeser, M.D. ¶
¶ Division of Gastroenterology, Department of Medicine, Bridgeport Hospital-Yale
SC
New Haven Health, Bridgeport, CT
M AN U
To the Editor:
Myasthenia gravis is a well characterized autoimmune disorder caused by an antibody mediated attack of the acetylcholine receptors in the post synaptic membrane of the neuromuscular junction. Initial presentation is typically characterized by progressive
TE D
muscle fatigability, most commonly targeting the ocular system, and resulting in ptosis and diplopia. Bulbar manifestations, such as dysarthria and dysphagia, are more commonly seen in, although not limited to, elderly male populations. Signs and
EP
symptoms of bulbar weakness, rather than ocular manifestations, have been reported to occur as the presenting symptoms of myasthenia; however, this is exceedingly less
AC C
common, accounting for only six percent of cases.1 We hereby describe the case of a 64-year-old male, with past medical history of hypertension, and hypothyroidism secondary to Hashimoto’s thyroiditis, who presented with a primary complaint of progressive dysphagia to both solid and liquids. Additional signs and symptoms included dysarthria, upper and lower extremity weakness and a 40 pound weight loss over the previous 2 months. His family noted that he experienced intermittent left eye droop. Physical examination was significant for left eyelid ptosis and a miotic left pupil. Muscle strength was 1/5 2
Myasthenia gravis presenting with dysphagia
ACCEPTED MANUSCRIPT in the upper and lower extremities bilaterally. Sensation was intact throughout. Shortly after admission to the hospital, the patient required intubation secondary to respiratory failure due to exhaustion of the respiratory muscles. Upper endoscopy findings included a small hiatal hernia but no obstructive lesion was
RI PT
seen. Barium swallow demonstrated reduced lingual strength, severely delayed
swallow reflex, and weak bolus propulsion. Electromyographic evaluation was
suggestive of a myopathic process. Acetylcholine receptor binding antibody (AChR-
SC
Ab) was >75nmol/L (normal
