292 J La State Med Soc VOL 154 November/December 2002 Journal of the Louisiana State Medical Society CLINICAL CASE OF THE MONTH TARGET AUDIENCE The November/December Clinical Case of the Month is intended for family physicians, general internists, general practitioners, emergency medicine physicians, pediatricians, radiologists, and neurologists. EDUCATIONAL OBJECTIVES The Clinical Case of the Month is a regular educational feature presented by the Louisiana State University Department of Medicine in New Orleans. Medical stu- dents, residents, postdoctoral fellows, and faculty col- laborate in the preparation of these discussions. After reading this article, physicians should be able to bet- ter identify and understand the pathophysiology, clinical presentation, diagnosis, and treatment of my- asthenia gravis. CREDIT The LSMS Educational and Research Foundation des- ignates this educational activity for a maximum of one (1) hour of category 1 credit toward the AMA Physician’s Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity. DISCLOSURE Dr. Sondes has nothing to disclose. Dr. Kennedy has nothing to disclose. Dr. Kishner has nothing to disclose. Dr. Lopez discloses that he is a member of the LSMS Journal Board and the LSMS Journal Editorial Board. Dr. Anthony has nothing to disclose. Original Release Date Expiration Date 12/31/2002 12/31/2003 Estimated time to complete this activity is 1 hour. CME INFORMATION A 58 year-old man presented to our facility com- plaining of a one-week history of increasing difficulty in “holding his head up.” About eight months earlier, he had begun to experience generalized muscle weakness, which worsened in the evenings. This weakness progressed gradually until ambulation and activities of daily life became difficult. He could not even hold his head up without the use of a cervical collar (Figure 1). In addition, he complained of some difficulty with breathing and swallowing. He also reported a forty-pound weight loss over the preceding year. He denied fevers, chills, or malaise, and his symptoms were not associated with any pain, fatigue, sleepiness, cold intolerance, depression, orthopnea, or paroxysmal noc- turnal dyspnea. His past medical history was significant for hypothy- roidism diagnosed one year earlier and congestive heart failure diagnosed 4 months earlier. His medications in- cluded lisinopril, furosemide, digoxin, spironolactone, levothyroxine, and aspirin. With the exception of the levothyroxine, the patient was taking these medications as prescribed. He was allergic to penicillin and sulfa- Severe Progressive Weakness in a 58-Year-Old Man Scott Sondes, MD; John M. Kennedy, MD; Stephen Kishner, MD; Fred A. Lopez, MD; and Lowell Anthony, MD Myasthenia gravis historically has been associated with significant morbidity and mortality rates, and most of those afflicted either died of the disease or became greatly disabled. However, modern understanding of the pathogenesis of this disorder has led to several effective treatments which have transformed the prog- nosis of this disease greatly.