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Coexistence of ocular myasthenia gravis and Graves’ disease in a three years old female- Zaid Rasheed Al Ani- University of Anbar

Abstract

 A 14 years old female developed acute ptosis of the right eye at three years age followed by the second eye and diagnosed as myasthenia gravis after a positive response to SC neostigmine and normal fundoscopy, brain CT scan, and general investigations. The condition failed to respond to adequate Mestinon (Pyridostigmine) therapy. Five months later developed rolling of the eyes, convergent squint, bilateral ophthalmoplegia, proptosis, goiter and signs of Graves’ disease. Investigations showed high T4, low TSH, normal anti acetylcholine, ANA, anti SM antibodies, EEG, brain MRI, and CT scan of the chest. The condition diagnosed as a coexistence of myasthenia gravis with Graves’ disease. Carbimazole 5 mg/day was added but still the ophthalmoplegia and ptosis persist. Prednisolone added for three months but no response. As she passed more than three years with the disease without developing systemic signs of myasthenia gravis, the condition then diagnosed as ocular myasthenia gravis with Graves’ disease. With age, the ptosis and ophthalmoplegia interfered with her social and school performance in spite of the increased Mestinon therapy to 45 mg 6 hourly. In 2016 when she was 12 years old, reevaluation investigations showed all normal except enlarged thymus on CT scan of the chest and positive nasalis muscle EMG. Thymectomy was done after plasmapheresis. Three weeks after operation, ptosis starts to improve followed by gradual improvement of ophthalmoplegia. Now, after 2 years from operation, ptosis and ophthalmoplegia improved to about 70% and the euthyroid goiter reduced in size on only Mestinon 60 mg six hourly without antithyroid therapy.

Zaid Rasheed Al Ani

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