Completion of the Myasthenia Gravis Puzzle by Fitting Together the Seemingly Unrelated Symptom Pieces: A case report

Background: "Common" does not necessarily equate to being "easily recognized." Because of fluctuating skeletal muscle symptoms that may not present equivocally or even at the same time, Myasthenia gravis (MG) often goes undiagnosed, leading to a delay in diagnosis for months to years. This study describes a case of MG which evaded diagnosis multiple times, likely due to fluctuating symptoms and misread presenting symptoms at different individual encounters. Case Information: An 84-year-old female presented with shortness of breath, neck muscle pulling, and worsening generalized weakness. She was unable to stand up from her porch upon arriving home from a cardiology appointment. She exhibited abnormal gait, difficulty swallowing food, and episodes of choking. She also recently received glasses with prism lens by her optometrist due to double vision. Her examination was notable for binocular diplopia, decreased proximal muscle strength in bilateral upper and lower extremities, pressured speech, ptosis, and ataxia. Suspecting a neuromuscular diagnosis, acetylcholine receptor antibodies were ordered and returned positive, indicative of MG. Conclusions: Although MG is a common neuromuscular disease, its diagnosis can be difficult, due to vague fluctuating symptoms and potential for pathologic mimicry that lead physicians down unrelated rabbit holes that delay diagnosis. MG benefits from a broadened approach, taking into account all previous hospital visits, appointments, and symptomatology - as opposed to a limited view on any one symptom present at that encounter. With MG, it is essential to obtain a complete history, combining the seemingly unrelated pieces into the completed puzzle.