Endocrine Abstracts

JOINT1877

Introduction: Ptosis can indicate a variety of conditions, including neurological, muscular, or vascular disorders. In patients with autoimmune or inflammatory diseases, establishing a diagnosis can be challenging. We present the case of a sudden unilateral ptosis in a woman with Graves’ disease (GD) and Multiple Sclerosis (MS).

Case Presentation: A 53-year-old woman, was being monitored for GD, (TSH < 0.005 µUI/l, FT4: 28 pmol/l, mild bilateral Graves’ orbitopathy without symptoms of activity, and positive TSH receptor antibodies) treated with methimazole. She had type 2 diabetes, hypertension, and MS. The patient presented with sudden onset of left eyelid ptosis over two months. Clinical examination revealed ptosis with exotropia of the left eye, suggesting oculomotor nerve (III) palsy, without pupillary involvement. Other cranial nerves were intact, except for the known left abducens nerve palsy (VI). The right eye showed a subconjunctival haemorrhage, with no other abnormalities. Laboratory tests showed a slightly low TSH (0.09 µUI/l) with a normal FT4 level (16.9 pmol/l). Other biological parameters were within normal limits. A cerebral CT angiography ruled out aneurysm or carotid dissection.

Discussion: The ptosis in this patient presents a diagnostic challenge due to her multiple systemic conditions. Mechanical or traumatic origin was excluded based on imaging and patient history. MS could explain third cranial nerve involvement, but the gradual onset, lack of visual disturbances, and the absence of other typical symptoms make this less likely. Myogenic origin (myasthenia gravis), While autoimmunity is a risk factor, the sudden onset, non-fluctuating nature of the ptosis, and lack of worsening with exertion argue against this diagnosis. Vascular origin remains possible due to the patient’s vascular risk factors, but the absence of an internal carotid aneurysm on angiography reduces this likelihood. Further investigations are planned, including brain MRI with MR angiography, anti-acetylcholine receptor, anti-MuSK antibody testing, and electromyography.

Conclusion: This case underscores the diagnostic complexity of ptosis in patients with multiple comorbidities. A multidisciplinary approach is essential to identify the underlying cause.