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Case description
A 55-year-old man developed fatiguable binocular horizontal diplopia, ptosis, dysarthria and dysphagia that limited his oral consumption to fluids only. On examination, he had a complex ophthalmoplegia, fatiguable ptosis and facial diplegia. Neck flexion, masseter and temporalis muscles were mildly weak but tongue protrusion and palatal lift were normal. Respiratory function was preserved and limb examination unaffected.
He showed pronounced flaccid nasal dysarthria throughout the consultation while sitting. To facilitate conversation, he asked to lie supine, which he had learnt could alleviate such difficulties. While supine, he maintained a marked improvement in speech with less nasal escape.
Serum anti-acetylcholine receptor antibodies were positive (titres >20 nmol/L). CT scan of chest excluded a thymoma. We diagnosed generalised myasthenia gravis and started pyridostigmine and prednisolone, following national guidelines.1 The patient was admitted for plasma exchange, which was effective. …
Footnotes
Contributors JC identified the sign. JC and RM conceptualised the manuscript. JC and RM created the first draft. All authors contributed to the final version.
Funding JC is salary funded by the Guarantors of Brain under a Brain Entry Fellowship. The authors declare no other disclosures or funding relevant to this manuscript.
Competing interests None declared.
Provenance and peer review Not commissioned. Externally peer reviewed by Jon Walters, Swansea, UK and Tom Hughes, Cardiff, UK.
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