a 24-year-old lady with neck swelling and bilateral partial ptosis
DESCRIPTION
Case presentation in the Department of Endocrinology, BSMMU on 5th November, 2013.TRANSCRIPT
Dr. Mohammad Walidur RahmanDr Pritam Kumar
Resident , Phase A (Cardiology)
Patient Information
Name Ms X
Sex Female
Age 24 years
Address G
Date of admission 27-10-2013
Presenting complaints
Progressive swelling in the neck- 4 yrs
Drooping of both eyelids- 2 yrs
Presenting complaints
Swelling in the neckNoticed four years backProgressiveAssociated with
○ Heat intolerance○ Weight loss○ Excessive sweating○ Hyperdefecation○ irritability
Bulging of both eyeballs6 months after initial symptomsAssociated with
○ redness ○ retro-orbital pain ○ increased lacrimation ○ double vision
Drooping of both eyelidsFor 2 years, more marked for last 7 monthsDiurnal variationInability to move the eye in all directions
H/O occasional swallowing difficulty, nasal regurgitation
No history of slurring of voice
No history suggestive of RA , SLE , DM or Addisons disease
Past history: Nothing significant
Family history : No history of such illness or any autoimmune disorder
General Examination
Bilateral partial ptosis Diffusely enlarged thyroid
FirmNon tenderSmooth surfaceWithout retrosternal extensionThyroid bruit : absent
General Examination
Pulse : 72 beat/min BP : 120/80 mmhg Temp : 98 F Resp rate : 16 breath/min
Neurological examination
Bilateral partial ptosis Bilateral mild proptosis (Rt>lt)
Neurological examination: cont… Visual acuity: 6/9 on both eyes External ophthalmoplegia Intact Light reflex Fundus : Normal
Motor system : Reflexes are normal Sensory system : Normal
Investigations Test Name 21/09/2013
Hb 13.2 gm/dl
ESR 20 mm in1st hr
RBC 5X1012/L
Platelets 400X109/L
WBC 9.5X109/L
Neutrophil 69%
Lymphocytes
25%
Monocytes 04%
Eosinophils 02%
basophils 00%
27-07-11
19-05-13
18-08-13
18-09-13
26-10-13
28-10-13
s. TSH <0.05 microIU/ml
<0.01 microIU/ml
0.03 microIU/ml
0.018 microIU/ml
0.012 microIU/ml
S. FT3 7.03 ng/ml
30 pg/ml
14.5 pg/ml
3.10 pg/ml
S. FT4 >30 microgm/dl
60.64 Pmol/ l
5.10 ng/dl
1.85 ng/dl
1.15 ng/dl
19-05-13Anti TPO Ab : 637.78 iu/mlAnti TG Ab : >1000 iu/ml
25-05-13USG of thyroid : thyroid gland is markedly
enlarged in size(both lobes) with uniform echotexture
21-05-13
Tc 99 Scintigraphy : both lobes of thyroid gland is markedly enlarged in size with intensity increased & uniform radiotracer conc. Background activity is not seen
01-06-13RNS Test : pre & post exercise RNS
showed significant (>15%) decrease of CMAP in orbicularis oculi (lt)
02-06-13Anti ach-R Ab : 15.5 nmol/l
06-06-13HRCT of Chest : Enlarged thymus
Investigations 28/05/13 28/10/2013
FPG2h ABF
4.4 mmol/L7.7 mmol/l
Serum Creatinine
0.4 mg/dl 0.6 mg/dl
Serum Albumin 36 gm/l
SGPT 47 U/L 50 U/L
Na 148 mmol/l 144 mmol/l
K 3.8 mmol/l 4.4 mmol/l
Cl 106 mmol/l 108 mmol/l
Calcium 9.1 mg/dl
RBS 4.4 mmol/l
24-06-13CT scan of brain & orbit : normal
29-10-13ECG : Within normal limitChest X – Ray : normal
Diagnosis
Graves’ thyrotoxicosis with ophthalmopathy
Myasthenia Gravis
Disease course
Medication : Carbimazole 30 mg/day ( 22/05/13 – 27/
5/13)20 mg/day ( 27/ 5/13 – 20/8/13)45 mg/day (20/8/13 – till now)Propranolol 20 mg/day Pyridostigmine 30mg BD (S.F 01/06/13)
Symptoms of toxicosis resolved within 2-3 wks
Symptoms of myasthenia improved initially
But later on she experienced worsening of ptosis & dysphagia
On 24/09/13 she became restless which was associated with dyspnea & dysphagia
It was preceded by cough & fever Got admitted into DMCH Treated as Myasthenic crisis
High flow oxygenIV CeftriaxoneIV dexamethasone
Now she is waiting for Thymectomy
Diagnosis
Graves’ thyrotoxicosis with ophthalmopathy
Myasthenia Gravis with H/O Myasthenic crisis
Problem list
How to prepare the patient for Thymectomy?
Role of steroid ?
Is beta blocker a contributor for poor respone of Myasthenia?
THANK YOU