Case Record of the Massachusetts General Hospital: A 74-year-old man was admitted to the hospital because of dyspnea, proximal muscle weakness, and hypoxemia.
The patient had been in his usual state of health, with hypertension and dyslipidemia, until 7 months before the current presentation, when intermittent binocular diplopia developed. Evaluation by an ophthalmologist affiliated with this hospital revealed ptosis in the right eye and fluctuating strabismus that was not associated with a cranial nerve abnormality. Testing for acetylcholine receptor antibodies was positive, and computed tomography of the chest showed a normal thymus. Treatment with pyridostigmine was started for presumed ocular myasthenia gravis, and the patient was referred to the neurology clinic affiliated with this hospital.
On examination, the temporal temperature was 37.2°C, the blood pressure 112/64 mm Hg, the heart rate 111 beats per minute, the respiratory rate 22 breaths per minute, and the oxygen saturation 87% while the patient was breathing ambient air. The oxygen saturation increased to 98% while supplemental oxygen was delivered through a nasal cannula at a rate of 5 liters per minute. The body-mass index (the weight in kilograms divided by the square of the height in meters) was 24.5. He had horizontal diplopia on sustained upward gaze and weakness on eye closure. Strength was 4/5 on elbow extension, elbow flexion, and hip flexion; strength was 5/5 on shoulder abduction but 4/5 after 20 repetitions. Strength was otherwise 5/5. The patient’s voice was hoarse, but his speech was not nasal. He was able to count to 16 in one breath. Mild dysarthria was present. On examination of the tongue, there was a raised erythematous area on the dorsal aspect, ulcerated lesions on the lateral aspect, and a white exudate on the dorsal aspect (seen in Panels A–C). Mild pitting edema in the ankles was observed. No rash was present.
Read the full case details in “A 74-Year-Old Man with Dyspnea, Proximal Muscle Weakness, and Hypoxemia,” a Case Record of the Massachusetts General Hospital (@MassGeneralNews), by P.O. Ankomah et al.: https://t.co/JRlVAVt9PL
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