Droopy eyes-Mystry solved!

This young female patient came to the ER with the c/o severe generalized weakness, double vision, drooping of eyelids. She first went to some local eye doctor thinking of it as conjunctivitis or stye but the doctor could not quite make out the diagnosis and advised her to get a CT scan of brain. But due to the increasing severity of her disease one day she came to our hospital emergency room. Fortunately, I was on duty at that time, so, I got the opportunity to examine the patient at the first visit. She had bilateral asymmetrical ptosis along with near total ophthalmoplegia in her both eye. Her power in the upper limb was of grade-3+ and in the lower limb grade-2+. Her muscle tone and tendon jerks were diminished in the both upper & lower limb but bladder bowel function was unaltered. She had an intact sensory system functioning and her cranial nerves other than IIIrd, IVth & Vth was absolutely normal. She neither had diabetes/hypertension nor any major illness in the past. There was no h/o snake bite or intake of adulterated food in the recent past. To rule out any gross intracranial pathology, I asked her immediately to get a CT scan of brain which came completely normal. At this stage I was a bit puzzled. What could be the diagnosis??

 But then one possibility clicked in my mind, I gave her Neostigmine (Myostigmine) injection test dose 1.5 mg IM along with inj. Atropine 0.4 mg IV stat. After a while, when I was busy in attending other patients, her husband came through and asked me to have a look at her wife. I was totally shocked when I saw her sitting in the bed, smiling and looking brightly at me. Her ptosis, ophthalmoplegia, limb weakness were seemed to have vanished like a magic. She and her husband both were very happy and expressed their gratitude to me. She was then admitted in the ward and on further evaluation her N-Ach receptor Antibody titre was found to be highly elevated, electrodiagnostic test with RNST was also corroborative with the diagnosis. CECT of mediastinum was done too in which thymoma was detected. So, we got the diagnosis now, it is Myasthenia gravis.

She was started on Tab Gravitor 60 mg TDS along with Tab. Prednisolone 30 mg OD. She improved eventually and was referred to a specialized center for thymectomy surgery.