CentraState - Healthy Directions

8 Spring 2014 Healthy Directions Mistaking Friends for Enemies: How Antibodies Go Astray in Myasthenia Gravis W hile six to eight months ago she was taking the bus to the supermarket and carrying her own bags home, 88-year-old Elizabeth Goldstein now couldn't walk down the aisle at her granddaughter's wedding without assistance. Over the past year, Elizabeth experienced a range of seemingly unconnected symptoms. Her recurrent eye secretions, double vision, weight loss, and general sense of weakness were all attributed to an earlier cataract surgery, the steady deterioration of aging, and a possible underlying depression. Early in November, Elizabeth was admitted to CentraState with shortness of breath. After grappling with the contrast between what appeared on the chest X-rays and the severity of her lung functions, the pulmonary physicians ruled out a pulmonary basis for her illness, calling in the neurohospitalists at CentraState, who specialize in inpatient neurological care. Anita Mehta, DO, board-certified neurologist and on staff at CentraState, evaluated Elizabeth for a range of neurological impairments. "If people have blurry vision, it's nonspecific. If someone is complaining of double vision, that's neurologically based," Dr. Mehta explains. It would take days for some of the test results to come back. Meanwhile, Elizabeth was failing quickly. She had advanced to respiratory failure and was breathing largely with the help of a mechanical ventilation mask. Dr. Mehta's associate, Yih Lin Nien, MD, board-certified neurologist and medical director of the Stroke Center at CentraState, then joined Elizabeth's treatment team. When he temporarily removed Elizabeth's breathing mask to examine her, he noticed some telltale signs of a specific autoimmune disorder: myasthenia gravis. Elizabeth was displaying the drooping eyelids and weak facial muscles characteristic of the condition. A relatively uncommon disorder, myasthenia gravis typically affects women in their 20s and 30s or men in their 60s and 70s. It can affect only the eyes (ocular myasthenia gravis) or involve a combination of facial, neck, limb and respiratory muscles (generalized myasthenia gravis), but in both cases, the patient's antibodies have mistakenly attacked the communication receptors between their nerves and muscles, viewing them as invaders. The muscles are unable to respond to commands to contract, resulting in a pervasive muscle weakness. Although Elizabeth fit neither the typical age nor gender categories, her symptoms pointed to myasthenia gravis. "The diagnosis can be made based on the patient's history and the visible findings in an exam," Dr. Nien explains. "Whenever a person develops droopy eyelids, double vision, or any weakness in the facial muscles, that raises a red flag and needs a neurological evaluation." The confirmatory test would take some time to come back, and Dr. Nien recommended immediate treatment. Time was not on Elizabeth's side. Elizabeth had been moved to the intensive care unit, where she could be more closely monitored. Hopes for recovery were low, as it would be difficult for Elizabeth, at 88, to recuperate. Her family was prepared to say their goodbyes. "We thought there was no way she would survive this," recounts her son, Hal, shaking his head. Five days of intravenous immunoglobulin treatment, however, halted the damaging work of the antibodies and Elizabeth Goldstein has made a remarkable recovery after receiving treatment for myasthenia gravis at CentraState.

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