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Case Report

Myasthenia gravis masquerading as acute sixth nerve paresis following head trauma – or vice versa? A case report

Authors:

Danielle E. Eckersley ,

Frimley Park Hospital NHS Trust, Frimley, Surrey
About Danielle E.
BSc (Hons)
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Lorraine North,

Frimley Park Hospital NHS Trust, Frimley, Surrey
About Lorraine
MSc BSc (D)
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J. Govan

Frimley Park Hospital NHS Trust, Frimley, Surrey
About J.
FRCS MRCP FRCOphth
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Abstract

Aim: To report a case of sudden-onset diplopia, blurred vision and an inability of the left eye to fully abduct following trauma. Subsequent examinations showed significant variability leading to a possible diagnosis of myasthenia gravis.

Methods: This is a case report of a 7-year-old boy with a 2-day history of blurred vision, horizontal diplopia and headaches following a bump to the left side of his head that presented as a left sixth nerve paresis. The history, orthoptic findings, investigations and possible aetiologies are discussed.

Results: Orthoptic assessments initially revealed a marked left esotropia with restriction on left abduction. Computed tomography (CT) scans and magnetic resonance imaging (MRI) were both normal, as was monitoring of the patient’s intracranial pressures. Further orthoptic assessments demonstrated normal ocular movements on some visits whilst on other visits a restriction of left abduction was still shown. The patient then developed a vertical element with ptosis with significant variability at each visit, leading to a possible diagnosis of ocular myasthenia gravis. He was started on pyridostigmine and improvement was observed. However, low-affinity acetylcholine receptor antibodies, MuSK antibodies, Tensilon test and nerve fibre stimulation were negative and pyridostigmine was stopped.

Conclusion: A question mark still hangs over the aetiology of this case. After a year of monitoring it was decided that the most suitable management for this patient was botulinum toxin. Following one injection the patient is currently straight and demonstrating stereopsis

DOI: http://doi.org/10.22599/bioj.61
How to Cite: Eckersley, D.E., North, L. & Govan, J., (2012). Myasthenia gravis masquerading as acute sixth nerve paresis following head trauma – or vice versa? A case report . British and Irish Orthoptic Journal . 9 , pp . 74–77 . DOI: http://doi.org/10.22599/bioj.61
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Published on 01 Aug 2012.
Peer Reviewed

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