A young lady with progressive neck swelling and bilateral partial ptosis
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A case presented in Medicine Grand Round in BSMMU on 2nd June, 2013 by Dr. Mohammad Atiqur Rahman (Phase B Resident, Endocrinology & Metabolism)
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A young lady with progressive neck swelling and bilateral partial ptosis
- 1. A young lady with progressive neck swelling & bilateral partial ptosis Presenter Dr. Mohammad Atiqur Rahman Resident phase –B Depatment of Endocrinology
- 2. Particulars • 24 years • Female • Student • Admitted on 25/05/2013
- 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 features of thyrotoxicosis • Bulging of both eyeballs – 6 months after initial symptoms – Associated with redness, retro-orbital pain, increased lacrimation & double vision
- 5. Presenting complaints: cont… • Visited several physicians & was treated with different medications with partial improvement • Drooping of both eyelids – For 2 years, more marked for last 2 months – Diurnal variation – Inability to move the eye in all directions • H/O occasional swallowing difficulty, nasal regurgitation • No history of limb weakness
- 6. • Past history: Nothing significant • Family history : No history of such illness or any autoimmune disorder • Menstrual history: – Oligomenorrhea
- 7. General Examination • Bilateral partial ptosis • Diffusely enlarged thyroid – Firm – Non tender – Smooth surface – Without retrosternal extension – Thyroid bruit : present
- 8. Photographs are used with permission of the patient
- 9. Thyromegaly Photographs are used with permission of the patient
- 10. General Examination: cont… • Warm, sweaty hands • Fine tremor • Pulse : 120/min, regular • Bp : 120/50 mm of Hg
- 11. Neurological examination • Bilateral partial ptosis • Bilateral mild proptosis (Rt>lt) Photographs are used with permission of the patient
- 12. Neurological examination: cont… • Visual acquity: 6/9 on both eyes • Complete external ophthalmoplegia • Intact Light reflex • Fundus : Normal • Motor system : Reflexes are exaggerated • Sensory system : Normal
- 13. ICE-ON-EYES TEST 5 mm 12 mm Photographs are used with permission of the patient
- 14. Investigations • CBC : Normal • TSH : <0.01 µIU/ml (0.4-4) • FT4 : 60.64 pmol/L (9.13-23.8) • FT3 : 30.0 pgm/ml (1.8-4.7) • Anti TPO : 637.78 IU/ml (upto 35) • Anti TG : >1000 IU/ml (upto 40) • Thyroid scan : Markedly enlarged thyroid with uniform radio tracer concentration
- 15. Investigations: cont… • FPG: 4.4 mmol/L • 2h-PG: 7.7 mmol/L • SGPT: 47 U/L • S. Creatinine : 0.4 mg/dl • S. Calcium : 9.1 mg/dl (9-11) • S. Albumin : 36 gm/L • S. Electrolytes : Normal
- 16. Investigations: cont… • Chest X ray : Normal • Repetitive nerve stimulation
- 17. Hospital course • Current Medication : – Carbimazole 30 mg/day (S.F 22/05) – Propranolol 20 mg/day – Pyridostigmine 30mg BD (S.F 01/06) • Worsening of nasal regurgitation and weakness of facial muscles
- 18. Diagnosis • Graves’ thyrotoxicosis with ophthalmopathy • Myasthenia Gravis
- 19. Problems • Need for any further evaluation? – CT chest – Anti AchR – Anti MuSK • Treatment plan
- 20. Acknowledgement • Prof. Dr. Md. Fariduddin • Dr. M A Hasanat • Dr. Sandesh Panthi • Dr. Mashfiqul Hasan • Dr. Yasmin Aktar • Other colleagues • Patient and her attendants
- 21. Thank You
- 22. ‘‘Ice-on-eyes’’, a simple test for myasthenia gravis presenting with ocular symptoms Pract Neurol 2007; 7: 109–111