Endocrine Abstracts

23-year male presented to Endocrinology OPD with 5 months history of bilateral eye prominence and left-eyelid drooping, evening-worsening of ptosis and ocular fatiguability in the form of intermittent diplopia. Initial consultation with a neurologist revealed diagnosis of ocular myasthenia gravis. Patient’s autoimmune markers including anti AChR and anti Musk were negative, although RNST was suggestive of NMJ disorder and CE-MRI Brain was normal. He was started on Pyridostigmine following which mild improvement noticed in ptosis but patient discontinued therapy. Few months later patient reconsulted neurophysician. RNST was repeated which revealed findings consistent with thyrotoxicosis (Graves’ disease). Endocrinologist’s opinion sought thereafter. On detailed history assessment there were no symptoms suggestive of thyrotoxicosis. Eye examination by exophthalmometer revealed proptosis [22/23 mm (L/R)]. There was moderate left ptosis with palpebral aperture height 8 mm, MRD 1 = 2 mm. Right eye palpebral aperture height was 15 mm with superior / inferior limbus visualized, MRD 1 = 8 mm, MRD 2 = 7 mm. He also had restricted left lateral gaze. Left eye ptosis improved with ice pack application. Rest of the neurological examination was unremarkable. Patient’s routine biochemistry was unremarkable. TFT revealed thyrotoxicosis, elevated TRAb antibodies; thyroid nuclear scan revealed hyperthyroidism (Graves’ disease). Contrast CT of neck/chest revealed normal thymus morphology. MRI bilateral orbits was unremarkable. He was started on an antithyroid drug - Carbimazole (20 mg twice daily), Pyridostigmine (60 mg q8h followed by q6h) and received a short methylprednisolone pulse (120 mg on day 1 followed by 60 mg once daily on days 2–4). Patient follow up at 2 weeks revealed ptosis improvement with left eye palpebral aperture height of 12mm without diplopia. Proptosis remained stable without new inflammatory signs. Patient was finally diagnosed with ocular myasthenia gravis and Graves’ disease with mild inactive TED(EUGOGO).