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I'm Weak, but Why?

Topic: Adult

Created on Saturday, November 8 2008 by rednucleus

Last modified on Saturday, November 8 2008.

A 32-year-old woman presents with painless fatigable weakness and bilateral partial ptoses. Her deep tendon reflexes are intact, as is her sensory system. She a refugee from Somalia and her English is very poor in spite of being in the States for the past 4 years. Which one of the following is helpful in discovering the cause of her presentation?

A) Double vision on looking to the left

B) Ulnar deviation of her hand fingers

C) Posterior mediastinal mass

D) Normal visual acuity

E) Stress incontinence

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This question was created on November 08, 2008 by rednucleus.
This question was last modified on November 08, 2008.

ANSWERS AND EXPLANATIONS

A) Double vision on looking to the left

This answer is incorrect.

This features goes with her diagnosis of myasthenia gravis, but does not give a clue to the underlying cause! (See References)

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B) Ulnar deviation of her hand fingers

This answer is correct.

Please, read the question well; “…helpful in discovering the cause of her presentation?” So, you should look for something that might give a clue to the cause of her myasthenic features, and not for something that confirms that she has myasthenia. Does she have rheumatoid arthritis and she is on penicillamine?! Penicillamine is a well-recognized cause of drug-induced myasthenia. Whom to screen for myasthenia gravis development? The answers is patients on penicillamine or interferon beta therapy; those who underwent bone marrow transplantation; and neonates of myasthenic mothers. (See References)

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C) Posterior mediastinal mass

This answer is incorrect.

An anterior mediastnial mass may represent thymoma; thymoma is a well-known association with myasthenia gravis. One third of thymomas are malignant. All myasthenic patients with thymoma should be considered for thymic surgical removal, regardless of disease duration, severity, acetylcholine receptor antibody status, or patient’s age. A lung mass may be due to lung cancer; when the clinical features are suggestive, think of paraneoplastic Lambert-Eaton. (See References)

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D) Normal visual acuity

This answer is incorrect.

Myasthenia gravis does not tackle visual acuity, although double vision (from ocular muscle weakness) interferes with the patient’s visual picture. (See References)

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E) Stress incontinence

This answer is incorrect.

No relation at all! Stress incontinence is usually due to pelvic floor weakness in grand multiparous women. (See References)

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References:

1. Victor, M., and Ropper, A.H. (2001). Adams and Victor's Principles of Neurology, 7th Edition. McGraw-Hill, New York. (ISBN:0070674973)

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adult
I'm Weak, but Why?
Question ID: 110808056
Question written by rednucleus. (C) FrontalCortex.com 2006-2009, all rights reserved. Created: 11/08/2008
Modified: 11/08/2008
Estimated Permutations: 120