A Case of Myasthenia Gravis Presenting Solely with Bulbar Palsy not associated with Easy Fatigability

Myesthenia Gravis (MG) is a neuromuscular disorder characterized by weakness and fatigability of skeletal muscles as a result of decrease in numbers of available acetylcholine receptors (AChRs) at neuromuscular junction due to an antibody-mediated autoimmune attack. We present here male case of Myesthenia Gravis who presented with complaints of unable to drink water and coming out from nose while swallowing. Gradually he developed inability to eat.2 months later patient developed slurring of speech followed by total inability to speak. Also developed diplopia on binocular vision. On cranial nerve examination 3, 7, 9, 10th nerve palsies seen in the form of absence of medial& upward movement of left eye (3rd C. N. ), inability to close eyes completely (3rd C. N. ), reduced power and tone of buccinators muscle (7th C. N. ), gag reflex absent (9th C. N. ), presence of dysphagia (10th C. N. ). Rest of the CNS findings were normal. ANA was (+) with nuclear speckled pattern. VEP study was normal. EMG NCV showed reduced amplitude of bilateral facial nerve, involvement of right oculomotor nerve suggesting bulbar myasthenia greater thangeneralized myasthenia. Then we did AChR antibody test which came highly positive. He was started T. Pyridostigmine 60mg TDS and T. Prednisolone 5mg/kg and discharged. On follow up we found marked improvement of symptoms.