Ocular Myasthenia Gravis, Hashimoto's Thyroiditis, Iron Deficiency Anemia, and Reactive Hypoglycemia - Case Report

Abstract
Myasthenia gravis (MG) may occur in association with other organ- specific or nonspecific autoimmune diseases. In our study, we present a patient with ocular myasthenia, Hashimoto's thyroiditis, and iron deficiency anemia who later developed reactive hypoglycemia. A 25-year-old woman with complaints of fluctuating extraocular muscle weakness, ptosis, and diplopia was examined. MG, type I (ocular MG), was confirmed by an elevated titer of anti-acetylcholine receptor antibodies in serum (7 nmol/l, normal <0.6) and positive edrophonium test. Nerve conduction studies, needle electromyography, repetitive stimulation tests, and mediasten MRI were normal. The coexistence of Hashimoto's thyroiditis was diagnosed by the presence of a diffuse thyroid enlargement, elevated titers of anti-thyroglobulin antibodies (211.8 IU/ml, normal 0-115), thyroid peroxidase antibodies (356.4 IU/ml, normal 0-34), thyroid stimulating hormone (8.21 uIU/ml, normal 0.27-4.2), and a decreased titer of free-T4 (1.03ng/dl normal 1.8-4.6). Diplopia and ptosis have regressed with 180 mg/day pyridostigmine bromide. On her follow-up period, 8 months later, reactive hypoglycemia has been diagnosed. The coexistence of myastenia gravis, Hashimoto's thyroiditis and reactive hypoglycemia was not found in the literature. We should take into consideration the association and the importance of recognizing and treating these pathologies in myastenia gravis.