Case presentation in the Department of Endocrinology, BSMMU on 5th November, 2013.

1. Dr. Mohammad Walidur Rahman
Dr Pritam Kumar
Resident , Phase A (Cardiology)

2. Patient Information
Name
Ms X
Sex
Female
Age
Address
24 years
G
Date of admission 27-10-2013

3. Presenting complaints

Progressive swelling in the neck- 4 yrs

Drooping of both eyelids- 2 yrs

4. Presenting complaints

Swelling in the neck
Noticed four years back
Progressive
Associated with
○ Heat intolerance
○ Weight loss
○ Excessive sweating
○ Hyperdefecation
○ irritability

5. 
Bulging of both eyeballs
6 months after initial symptoms
Associated with
○ redness
○ retro-orbital pain
○ increased lacrimation
○ double vision

6. 
Drooping of both eyelids
 For 2 years, more marked for last 7 months
 Diurnal variation
 Inability 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

7. 
Past history: Nothing significant

Family history : No history of such
illness or any autoimmune disorder

8. General Examination


Bilateral partial ptosis
Diffusely enlarged thyroid
Firm
Non tender
Smooth surface
Without retrosternal extension
Thyroid bruit : absent

9. General Examination




Pulse : 72 beat/min
BP : 120/80 mmhg
Temp : 98 F
Resp rate : 16 breath/min

10. Neurological examination


Bilateral partial ptosis
Bilateral mild proptosis (Rt>lt)

11. 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

12. 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%

13. 27-0711
19-0513
18-0813
18-0913
26-1013
s. TSH
<0.05
<0.01
0.03
0.018
0.012
microIU/ microIU/ microIU/ microIU/ microIU/
ml
ml
ml
ml
ml
S. FT3
7.03
ng/ml
30
pg/ml
14.5
pg/ml
S. FT4
>30
microg
m/dl
60.64
Pmol/ l
5.10
ng/dl
28-1013
3.10
pg/ml
1.85
ng/dl
1.15
ng/dl

14. 
19-05-13
Anti TPO Ab : 637.78 iu/ml
Anti TG Ab : >1000 iu/ml

25-05-13
USG of thyroid : thyroid gland is markedly
enlarged in size(both lobes) with uniform
echotexture

15. 
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

16. 
01-06-13
RNS Test : pre & post exercise RNS
showed significant (>15%) decrease of
CMAP in orbicularis oculi (lt)

02-06-13
Anti ach-R Ab : 15.5 nmol/l

06-06-13
HRCT of Chest : Enlarged thymus

17. Investigations 28/05/13
FPG
2h ABF
4.4 mmol/L
7.7 mmol/l
Serum
Creatinine
0.4 mg/dl
28/10/2013
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

18. 
24-06-13
CT scan of brain & orbit : normal

29-10-13
ECG : Within normal limit
Chest X – Ray : normal

19. Diagnosis

Graves’ thyrotoxicosis with
ophthalmopathy

Myasthenia Gravis

20. 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)

21. 



Symptoms of toxicosis resolved within 23 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

22. 


It was preceded by cough & fever
Got admitted into DMCH
Treated as Myasthenic crisis
High flow oxygen
IV Ceftriaxone
IV dexamethasone

Now she is waiting for Thymectomy

23. Diagnosis


Graves’ thyrotoxicosis with
ophthalmopathy
Myasthenia Gravis with H/O Myasthenic
crisis

24. Problem list

How to prepare the patient for
Thymectomy?

Role of steroid ?

Is beta blocker a contributor for poor
respone of Myasthenia?

25. THANK YOU