Myasthenia gravis (MG) is a devastating autoimmune disease that involves the acetylcholine receptor (AchR) in the postsynaptic membrane of the neuromuscular junction. It is not uncommon for MG to accompany with other autoimmune diseases and complicate with multiple organ dysfunction. Here, we report on an 18-year-old female patient with a rare case of MG concomitant with thymus hyperplasia, diabetes mellitus, and hyperthyroidism. After full excision of the hyperplastic thymus gland, the patient's muscle weakness was greatly improved and her blood glucose level was restored to normal at the 6-month follow-up.Keywords Myasthenia gravis . Diabetes . Thymus hyperplasia . Hyperthyroidism . Thymectomy
CaseAn 18-year-old female, without positive family history, complained of right eyelid drooping, diplopia, and masticatory muscle weakness for 3 months. Her symptoms were alleviated with pyridostigmine bromide (120 mg/day). She was admitted with a 3-day history of dyspnea and myasthenia of the limbs. Physical examination revealed tachycardia (139/ min), reduced muscle tension of her limbs (level IV), abated tendinous reflex, and a positive fatigue test and a neostigmine test. Her Osserman classification was myasthenia gravis (MG) type IIB. Pyridostigmine bromide (120 mg/day) and methylprednisolone (500 mg/day) helped reduce her symptoms. Laboratory analyses indicated that her serum potassium was 4.62 mmol/L (reference interval [RI], 3.5-5.5 mmol/L), fasting plasma glucose was 8.0 mmol/L, urinary glucose was (++), her 75 g/2 h oral glucose tolerance test (OGTT) was 14.2 mmol/L, thyroid-stimulating hormone (TSH) was 0.007 μIU/mL (RI, 0.27-4.2 μIU/mL), free T4 was 63.59 pmol/L (RI, 12.0-22.0 pmol/L), free T3 was 11.60 pmol/L (RI, 3.1-6.8 pmol/L), thyroid globulin antibody was 30.45 IU/mL (RI <115.0 IU/mL), anti-thyromicrosomal antibody (ATM-Ab) was 61.73 IU/mL (RI<35.0 IU/mL), thyroid peroxidase antibodies (TPO-Ab) were 396.98 IU/mL (RI<300.0 IU/mL), and TSH receptor antibody (TR-Ab) was 17.2 IU/mL (RI< 9.0 IU/mL). In addition, she was positive for acetylcholine receptor antibodies (AChR-Ab), serum antibodies of glutamic acid decarboxylase (anti-GAD) and islet cell antibodies (ICA), and negative for insulin autoantibody (IAA). The thyroid ultrasound revealed multiple small follicles in both lobes. Chest computed tomography (CT) depicted a soft tissue in the thymus area of the anterior-superior mediastinum, which was considered thymus hyperplasia (Fig. 1a). The electromyogram suggested decreased muscle contraction and inconsistent or blocked fiber transmission. After a multidisciplinary round, the patient was treated with a full thymectomy under general anesthesia. Histological examination confirmed thymus hyperplasia (Fig. 2). The patient was finally diagnosed with MG accompanied with thymus gland hyperplasia, type I diabetes mellitus (DM), and hyperthyroidism.The patient had a MG crisis after surgery, which was managed with tracheotomy/ventilator-assisted breathing, pyridostigmine bromide, and glucocorticoids. Her...