Hickam's dictum: Myasthenia Gravis presenting concurrently with Graves' disease

Sehgal, Shekhar; Rebello, Roshan; Wolmarans, Louise; Elston, Marianne S.

doi:10.1136/bcr-2017-220153

Cited by 12 publications

(14 citation statements)

References 27 publications

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“…The possible association of neuromuscular disease with thyroid disorders was first described in 1953. In the subsequent decades, this link has frequently been reported [1]. Graves' disease occurs in approximately 5-8% of patients with myasthenia gravis [2].…”

Section: Discussionmentioning

confidence: 99%

Rare concurrent ocular myasthenia gravis and Graves’ ophthalmopathy in a man with Poland syndrome: a case report

Tang

Qin

2020

BMC Neurol

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Background Ocular myasthenia gravis and Graves’ ophthalmopathy are autoimmune diseases that are mediated by membrane receptors and share many identical clinical processes. Poland syndrome is a rare congenital deformity characterized by defects of the ipsilateral hand and the chest wall, and it is usually associated with hypoplasia of ipsilateral pectoral muscles and homolateral breast. However, to the best of our knowledge, the co-occurrence of these diseases has never been reported. In this study, we present a man with Poland syndrome who was diagnosed with Graves’ ophthalmopathy and ocular myasthenia gravis in succession. Case presentation A 43-year-old man presented with bilateral upper eyelid ptosis, bilateral eye protrusion, bilateral eye movement disorder and malformation of the right hand. Asymmetrical malformation of the chest wall and ipsilateral hand deformity were shown as Poland syndrome. He was diagnosed with ocular myasthenia gravis and Graves’ ophthalmopathy on the basis of clinical manifestations and laboratory examinations, including bilateral exophthalmos and progressive asymmetrical ophthalmoparesis without pupillary dysfunction, positive autoantibody tests, repetitive nerve stimulation tests, and computed tomography scans. Treatments with pyridostigmine bromide, thymectomy, and prednisone led to partial clinical improvement. After 13 months of follow-up, the symptoms of drooping eyelids were partially improved, but the eyeball protrusion and right hand deformity remained unchanged. Conclusions We report the first case of co-occurrence of ocular myasthenia gravis, Graves’ ophthalmopathy, and Poland syndrome. Genetic predisposition and immune dysregulation might be the pathogenesis of the association.

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Section: Discussionmentioning

confidence: 99%

Rare concurrent ocular myasthenia gravis and Graves’ ophthalmopathy in a man with Poland syndrome: a case report

Tang

Qin

2020

BMC Neurol

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“…Ocular signs can create diagnostic confusion in cases of concomitant MG in Graves’. [12] In other words, emergence of neuromuscular and bulbar symptoms during the treatment of thyrotoxicosis should alert the physician to suspect coexisting MG.…”

Section: Discussionmentioning

confidence: 99%

See-Saw Relationship and its Reversal after Immunotherapy in a Case of Graves’ Disease with Coexisting Myasthenia Gravis

Mallikarjuna

Velayutham

Sowmini

et al. 2019

Journal of Neurosciences in Rural Practice

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The unique association of myasthenia gravis (MG) with Graves’ disease in clinical practice emphasizes that one autoimmune disease can coexist with another or many. The relationship between these two entities has remained controversial till date. Some authors have reported a see-saw relationship between these two entities, MG waning with hyperthyroidism and waxing with treatment of hyperthyroidism. Treatment of both these disorders concurrently may be challenging at times as treatment for one entity may worsen the other. The use of beta-blockers and steroids for Graves’ disease may worsen myasthenic weakness. Antithyroid drugs can worsen myasthenia probably by immunomodulatory effects. We report a case of Graves’ disease coexisting with MG in a reciprocal relationship which was subsequently reversed after immunotherapy.

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“…Another retrospective study was done from 2008 to 2009 on 300 patients of MG for linkage of MG with thyroid disease. Study results showed that MG patients with positive thyroid antibodies have a higher number of AchR antibodies and more abnormalities with T cells [25]. Of all the thyroid diseases, Graves' disease is more frequent in patients with MG. Clinical features like neuromuscular weakness and ocular signs cause diagnostic confusion between two pathologies [24].…”

Section: Treatment Advances For Mgmentioning

confidence: 91%

“…This respiratory failure resulted after giving medication for his thyrotoxicosis, which unmasked the myasthenia gravis. Physicians should also consider MG in hyperthyroid patients presenting with neuromuscular weakness [25]. So, there is diagnostic confusion between MG and Graves' disease because of similarities in clinical features, and co-occurrence of these two autoimmune pathologies seen often in the same individual.…”

Section: Treatment Advances For Mgmentioning

confidence: 99%

Myasthenia Gravis and its Association With Thyroid Diseases

Amin¹,

Myat²,

Gandhi³

et al. 2020

Cureus

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Myasthenia gravis (MG) is a rare autoimmune neuromuscular junction disorder, and thyroid disorder is a disorder involving the thyroid receptor, of which Graves' disease (GD) is the most common autoimmune thyroid disorder, in which antibodies develop against thyroid receptors. Both may have similar clinical features. In myasthenia gravis, autoimmune antibodies develop against postsynaptic neuromuscular junction disrupting the neuromuscular transmission, resulting in fluctuating muscle weakness and fatigue. It is a disease of young women and older men. The two pathologies may coexist in a patient or can precede one another. Graves' disease (GD) among thyroid diseases is most often associated with MG. Similarities in clinical features lead to difficulty in distinguishing MG and GD. Despite the standard treatment of myasthenia gravis, including steroids, acetylcholinesterases, rituximab, immunosuppressants, and thymectomy, there is still an increased number of relapses and myasthenia crisis. Eculizumab and plasmapheresis are the two new treatment options for MG, with supporting evidence of marked improvement in recent studies. Myasthenia gravis and Graves' disease have a seesaw relationship. Treating one pathology may worsen the other, so physicians should always consider MG as a differential in patients of hyperthyroidism presenting with new symptoms of fatigue or respiratory failure or neuromuscular weakness. In this comprehensive review article, we tried to establish an association between myasthenia gravis and Graves' disease (GD) by exploring currently available literature from PubMed. However, more studies need to be done to establish an association between pathologies.

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Hickam's dictum: Myasthenia Gravis presenting concurrently with Graves' disease

Cited by 12 publications

References 27 publications

Rare concurrent ocular myasthenia gravis and Graves’ ophthalmopathy in a man with Poland syndrome: a case report

Rare concurrent ocular myasthenia gravis and Graves’ ophthalmopathy in a man with Poland syndrome: a case report

See-Saw Relationship and its Reversal after Immunotherapy in a Case of Graves’ Disease with Coexisting Myasthenia Gravis

Myasthenia Gravis and its Association With Thyroid Diseases

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