(Kiosk 4) Myasthenia Gravis Induced by Concussion: A Case Report

Case Diagnosis: A 55-year-old male was found to have seropositive Myasthenia Gravis likely triggered by concussion.

Case Description or Program Description: We present a patient who works as an NHL cameraman who was shooting a hockey game from outside the rink. During the game, 2 players collided into plexiglass, which then flexed and caused the camera to hit the right side of his face. Immediately following the trauma patient endorsed worsening lightheadedness, photophobia, headaches, and diplopia. He was initially evaluated with therapy recommended for treatment, however, he was lost to follow-up due to the retirement of his provider. He presented 1 year following initial trauma with persistent symptoms and worsening fatigue and ptosis of the right eye.

Setting: The patient was evaluated in an academic outpatient clinic.

Assessment/Results: On exam, the patient was found to have trace right internuclear ophthalmoplegia (INO) with nystagmus of left eye in abduction. Additionally with small esophoria in primary gaze that is slightly larger in right gaze. Immediate double vision to dawn gaze, and fatigable ptosis, after 20 seconds.

Labs obtained which demonstrated Acetylcholine receptor binding antibody elevated to 3.58 nmol/L (normal < 0.02 nmol/L). MRI brain was obtained with no abnormalities identified. CT Chest was obtained which was negative for thymoma.

He was started on pyridostigmine with an improvement of symptoms, however was discontinued due to gastrointestinal side effects. The patient started himself on Huperzine A with an improvement in vision deficits and fatigue.

Discussion (relevance): Visual abnormalities are a common post-concussive complaint. It is important to evaluate all symptoms following trauma and consider additional diagnoses, especially when symptoms worsen or don’t improve with time. Autoimmune diseases can be considered with systemic symptoms as these disease processes can be triggered during periods of high stress.

Conclusions: This case demonstrates the ability for concussion and other trauma to induce autoimmune processes. These diseases should be considered during evaluation.