|Title||A CASE OF COEXISTING NEUROPATHOLOGIES|
|Author, Co-Author||Shannon Huntzberry|
|Abstract|| BACKGROUND: A lesion at any location along the oculosympathetic pathway can produce a Horner's syndrome, causing paresis of involuntary muscles that are under sympathetic control. In contrast, myasthenia gravis is an immunologic disorder characterized by fluctuating weakness of voluntary ocular muscles. This case describes a single patient with Horner's syndrome, and the subsequent discovery of a superimposed myasthnia gravis on follow-up.
CASE REPORT(S): A 66-year old white male presented with an acquired, unilateral ptosis of one week duration. Exam revealed ipsilateral pupillary miosis, anisocoria greatest in dim illumination, and a distinct dilation lag. Cocaine testing confirmed the diagnosis of a left-sided Horner's syndrome, and a positive hydroxyamphetamine test localized a postganglionic lesion. MRI revealed a mucoserous retention cyst at the level of the ethmoid sinus with questionable compression of the sympathetic fibers in that area. Interestingly, on follow-up the patient reported an improvement of ptosis after periods of rest, and that the lid returned to a near normal level in cold temperature. In-office testing revealed worsening of ptosis with prolonged upward gaze, a positive Cogan lid twitch sign, and marked improvement of ptosis after prolonged ice pack application. Serological testing revealed elevated binding and modulating acetylcholine receptor antibodies, confirming the diagnosis of a coexisting myasthenia gravis.
CONCLUSIONS: Treatment with oral pyridostigmine, a cholinesterase inhibitor, improved the ptosis, and the patient has developed no signs of generalized disease to date. It is probable that the Horner's syndrome was longstanding, and that the ocular symptoms were a result of the myasthenia. Evaluation of the entire clinical picture in this case was critical in determining diagnostic work-up, prognosis, and treatment options for these two very separate clinical entities.
|Affiliation of Co-Authors|