Patient: Female, 44Final Diagnosis: MuSK myasthenia gravisSymptoms: Difficulty swallowing • double visionMedication: —Clinical Procedure: —Specialty: NeurologyObjective:Rare co-existance of disease or pathologyBackground:HIV infections with concomitant immunologically-mediated disorders have been frequently described but there has been little research on the association between HIV and myasthenia gravis.MuSK myasthenia gravis coexisting with HIV is an even a rarer entity and can occur as a part of immune restoration disease. We report the case of a patient with asymptomatic HIV infection who presented with new-onset MuSK myasthenia gravis.Case Report:A 44-year-old African-American woman with HIV since 2004 and on highly active antiretroviral therapy (HAART) presented to the ED with complains of double vision and difficulty swallowing for 2 weeks. The patient was intermittently on HAART therapy. On examination, she had bilateral ptosis, weak orbicularis oris and orbicularis oculi, along with mild lateral gaze palsy of the left eye. Her CD4 count was 383 and the viral load was undetectable. An MRI of the brain produced normal results and a CT chest did not show thymus enlargement. Due to worsening symptoms and high suspicion for myasthenia gravis, she was started on IVIG at 0.4 mg/kg/day for 5 days, and her symptoms markedly improved. She was found to have strongly positive MuSK antibody and negative Ach receptor antibody. Repetitive nerve stimulation showed a 13% decrease in the right median nerve, which confirmed the diagnosis. She was subsequently discharged to home on pyridostigmine. Azathioprine was added at clinic follow-up. The patient continues to improve.Conclusions:As the use of antiretroviral therapy increases, immune reconstitution syndromes have become more common. Rare associations like HIV and MuSK myasthenia gravis are being increasingly reported. The use of immunosuppressants in the treatment of these conditions should be carefully evaluated.

The clinical presentations of neuroleptic malignant syndrome (NMS) and malignant catatonia (MC) are similar, posing a diagnostic challenge. Here, we present a 58-year-old Caucasian male who presented to the emergency department with an altered mental state, fever, tachycardia, and rigidity. Labs were remarkable for elevated creatine phosphokinase (CPK) and leukocytosis. The patient was on a regimen of clozapine and cariprazine to manage schizophrenia, lorazepam to treat catatonia, and mirtazapine to treat insomnia and appetite stimulation. The patient was initially diagnosed with NMS after common metabolic, infectious, and substance-induced etiologies were ruled out. Within 72 hours of receiving dantrolene and lorazepam, the patient's fever, tachycardia, and other laboratory abnormalities resolved. However, when the patient's rigidity, waxy flexibility, mutism, and stupor persisted, the diagnosis was reconsidered and changed to MC. Our case discusses the overlapping clinical presentations of NMS and MC, demonstrating a diagnostic challenge.

Few case reports of catatonia associated with cannabis use are reported. Here, we describe a case of a 35year-old African American male who developed malignant catatonia following heavy cannabis use. The patient was brought to the emergency department (ED) for altered mental status, hypertension, and erratic behavior. Before his ED presentation, he was smoking cannabis in heavy amounts, confirmed by positive urine toxicology in ED. Initial lab results showed leukocytosis, elevated creatine phosphokinase (CPK) levels. Head CT scans without contrast, including cerebrospinal fluid (CSF) analysis, were nonsignificant. In ED, the patient was agitated, combative, mute, and rigid. He was sedated using 2 mg of intramuscular (IM) midazolam. Psychiatric consultation services suspected catatonia, and the patient scored 12 points on Bush-Francis Catatonia Rating Scale (BFCRS). Although the patient's symptoms responded to 2 mg of IM lorazepam, the patient later relapsed, became tachycardic with blood pressure fluctuations, and his repeat BFCRS score was 18. At this point, the patient was diagnosed as having malignant catatonia, and his lorazepam dosage was increased up to 6 mg IM per day. After a few days of waxing and waning of his symptoms, he finally started to show constant improvement and gradually reduced his symptoms. Our case highlights the first-ever reported case of malignant catatonia associated with cannabis use.

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Appearance of PHE did increase with gestational age, prior to 40 weeks, it was not uniformly present and was seen as early as 36 weeks independent of ethnic group.