Diffuse large B cell lymphoma mimics myasthenia gravis
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LETTER TO THE EDITOR
Diffuse large B cell lymphoma mimics myasthenia gravis Veronika Rutar Gorišek 1
&
David Zupančič 2 & Janez Zidar 3 & Alenka Horvat Ledinek 1
Received: 9 May 2019 / Accepted: 9 September 2019 # Fondazione Società Italiana di Neurologia 2019
Myasthenia gravis (MG) is the most common autoimmune disease affecting neuromuscular junction (NMJ) transmission [1]. It is characterized by muscle weakness that worsens with activity (fatigability). Ocular muscle weakness leading to ptosis and diplopia is the most common presenting feature. The diagnosis is usually suspected on clinical grounds and supported by specific neurophysiologic findings. The presence of serum acetylcholine receptor (AChR) antibodies confirms the diagnosis but is not mandatory. Chest CT scan is a part of the diagnostic work-up to evaluate the presence of thymoma. We present a case of a patient with asymmetrical ptosis, double vision, mediastinal tumour and neurophysiological abnormalities all due to disseminated B cell lymphoma. 71-year-old female complained of progressive double vision. Upon examination, neurologist found an impaired abduction of the right eye bulb and slight ptosis of the left eyelid that worsened after exertion. Other cranial nerve and limb examination was unremarkable. Ocular myasthenia gravis (OMG) was suspected, and she was scheduled to undergo neurophysiology testing, AChR antibody assay and chest CT scan. Two weeks later, the patient returned with complaints of symptom progression. She now complained of drooping of the right eyelid. She also mentioned pain behind her right eye and tingling sensation on the right side of her forehead. The right eyelid was in complete ptosis and the movement of Veronika Rutar Gorišek and David Zupančič contributed equally to this work. * Veronika Rutar Gorišek [email protected]; [email protected] 1
Department of Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia
2
Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
3
Clinical Institute of Clinical Electrophysiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
the right eye appeared limited in all gaze directions. The left eye exam was normal. A head CT scan revealed no evident pathology and the original diagnosis of ocular myasthenia appeared assertive. In support of the diagnosis, both the decrease of ptosis and an improvement of the right eye mobility after administration of 1 mg of pyridostigmine were noted by neurologist. The patient was prescribed pyridostigmine 30 mg four times per day. Neurophysiologic examination was performed 4 weeks later. Nerve conduction studies (NCS) did not reveal any abnormalities. Single fibre EMG (SFEMG) showed impaired neuromuscular transmission in the examined muscle (m. orbicularis oculi) with increased jitter in 15 out of 60 examined motor endplates. In repetitive nerve stimulation (RNS), complete block of neuromuscular junction (NMJ) transmission was found in 9%. There were no detectable serum anti
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