CASE REPORT 150|University of Pelita Harapan Case Report : Generalized Myasthenia Gravis Devita Widjaja 1 , Vivien Puspitasari 2 1 Faculty of Medicine, University of Pelita Harapan 2 Department of Neurology, Faculty of Medicine, University of Pelita Harapan Siloam Hospital Lippo Village Citation : Widjaja D, Puspitasari V. Case Report : Generalized Myasthenia Gravis Medicinus. 2019 October; 7(5):150–... Keywords : Myasthenia Gravis, Generalized *Correspondance : Vivien Puspitasari Faculty of Medicine University of Pelita Harapan, Department of Neurology, Siloam Hospitals Lippo Village E-mail : vivien.puspitasari@uph.edu Online First : June 2020 Abstract Generalized myasthenia gravis is a rare case of autoimmune wherein the antibodies destroy the post-sinaptic acetylcholine receptors at skeletal muscle’s neuromuscular junctions. The clinical presentation is specific distributin of motoric deficit without sensoric deficit which diminished with rest and worsens with excessive use. We report a case of a woman 52 yo with symptoms of ptosis, diplopia and dificulty of swallowing. Repetitive nerve stimulation showed >10% decrement and prostigmin test was positive. The patient was treated and showed clinical improvement. Introduction Myasthenia gravis is a rare case of autoimmune in which the antibodies destroy the post-sinaptic acetylcholine receptors at skeletal muscle’s neuromuscular junctions. It has a prevalence of 1.7-21.3 out of 1.000.000 people. The incidence is higher on women than men in ≤ 50 years old community (7:3), yet at >50 years old, men have more risk (3:2) 1 . Clinically, myasthenia gravis is divided into 2 subgroup : ocular and generalized. Patients with ocular myasthenia gravis only present with diplopia and ptosis. On the other hand, generalized myasthenia manifested as extraocular symptoms such as dysphonia, dysphagia, and even dyspnea 1,2 . Case In this case, 52 year old woman came to our outpatient department with difficulty of opening her right eye since 10 days ago which worsens gradually within 3 days. She also had diificulty gazing right and up, causing her to turn her neck. She could not see clearly due to double vision. She also had nasally and slurred speech, difficulty swallowing liquid and using straws hence often getting choked, diificulty chewing and closing her jaws since 2 months ago. All of her symptoms were getting worse at mid- day after activity, yet diminished with rest. She usually felt fine when she woke up in the morning. There was no limb or generalized weakness, dysarthria, pain, tingling, nor difficulty of breath. Patient and family members never had similar symptoms. She had a history of uncontrolled hypertension and diabetes mellitus. She did not smoke but became a passive smoker. She rarely consumed tinned food. Physical examination showed high blood pressure 140/90 mmHg. Cranial nerve examination showed she had heavy right eye ptosis 4mm/1mm. She also had 3 rd , 6 th , 7 th , and 9 th cranial nerve paresis. Specific wartenberg, simpson and counting tests were done and the results were positive. The patient had no sensoric dysfunction. Limb motoric and deep tendon reflexes were normal. Meningeal signs and pathological reflexes were not found. The patient was diagnosed with generalized myasthenia gravis and further diagnostic tests were done. Chest xray was done, no abnormality was found other than aorta elongation. Blood test was done and showed normal result. The patient was admitted into the ward. She was given ramipril and metformin. In order to prevent masking effect, myasthenia gravis medication was not given yet.