{"title":"Atypical Bulbar Myasthenia Gravis in an Elderly Male Unmasked by Levofloxacin: A Diagnostic Challenge.","authors":"Mrudula Thiriveedi, Anil Chimakurthy, Siddharth Patel, Sujatha Baddam, Rafik ElBeblawy, Punuru J Reddy","doi":"10.12890/2025_005386","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Myasthenia gravis (MG) is an autoimmune neuromuscular disorder that typically presents with ocular symptoms. Isolated bulbar symptoms, such as dysphagia and dysarthria, are rare, and most commonly seen in men with late-onset MG. We report one such rare case of MG in an 82-year-old male presenting with progressive bulbar weakness, seemingly triggered by levofloxacin use.</p><p><strong>Case report: </strong>An 82-year-old male with multiple comorbidities presented with progressive weakness, dysphagia, and drooling following levofloxacin therapy. Examination revealed neck drop, weak lower facial muscles, and dysarthria. Initial neuroimaging and labs were inconclusive. Neurology initiated pyridostigmine with rapid improvement. Elevated acetylcholine receptor antibodies confirmed MG. He was started on efgartigimod alfa in the outpatient setting with improvement in MG composite scores.</p><p><strong>Conclusions: </strong>Atypical bulbar MG can mimic other neurologic disorders and is prone to delayed diagnosis, especially in the elderly. Clinicians should maintain a high index of suspicion, particularly when symptoms worsen after medication exposures like fluoroquinolones. Early diagnosis and appropriate treatment can significantly improve outcomes and quality of life.</p><p><strong>Learning points: </strong>Levofloxacin can exacerbate or unmask myasthenia gravis.</p>","PeriodicalId":11908,"journal":{"name":"European journal of case reports in internal medicine","volume":"12 5","pages":"005386"},"PeriodicalIF":0.0000,"publicationDate":"2025-04-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12061212/pdf/","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"European journal of case reports in internal medicine","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.12890/2025_005386","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2025/1/1 0:00:00","PubModel":"eCollection","JCR":"Q3","JCRName":"Medicine","Score":null,"Total":0}
引用次数: 0
Abstract
Background: Myasthenia gravis (MG) is an autoimmune neuromuscular disorder that typically presents with ocular symptoms. Isolated bulbar symptoms, such as dysphagia and dysarthria, are rare, and most commonly seen in men with late-onset MG. We report one such rare case of MG in an 82-year-old male presenting with progressive bulbar weakness, seemingly triggered by levofloxacin use.
Case report: An 82-year-old male with multiple comorbidities presented with progressive weakness, dysphagia, and drooling following levofloxacin therapy. Examination revealed neck drop, weak lower facial muscles, and dysarthria. Initial neuroimaging and labs were inconclusive. Neurology initiated pyridostigmine with rapid improvement. Elevated acetylcholine receptor antibodies confirmed MG. He was started on efgartigimod alfa in the outpatient setting with improvement in MG composite scores.
Conclusions: Atypical bulbar MG can mimic other neurologic disorders and is prone to delayed diagnosis, especially in the elderly. Clinicians should maintain a high index of suspicion, particularly when symptoms worsen after medication exposures like fluoroquinolones. Early diagnosis and appropriate treatment can significantly improve outcomes and quality of life.
Learning points: Levofloxacin can exacerbate or unmask myasthenia gravis.
期刊介绍：
The European Journal of Case Reports in Internal Medicine is an official journal of the European Federation of Internal Medicine (EFIM), representing 35 national societies from 33 European countries. The Journal''s mission is to promote the best medical practice and innovation in the field of acute and general medicine. It also provides a forum for internal medicine doctors where they can share new approaches with the aim of improving diagnostic and clinical skills in this field. EJCRIM welcomes high-quality case reports describing unusual or complex cases that an internist may encounter in everyday practice. The cases should either demonstrate the appropriateness of a diagnostic/therapeutic approach, describe a new procedure or maneuver, or show unusual manifestations of a disease or unexpected reactions. The Journal only accepts and publishes those case reports whose learning points provide new insight and/or contribute to advancing medical knowledge both in terms of diagnostics and therapeutic approaches. Case reports of medical errors, therefore, are also welcome as long as they provide innovative measures on how to prevent them in the current practice (Instructive Errors). The Journal may also consider brief and reasoned reports on issues relevant to the practice of Internal Medicine, as well as Abstracts submitted to the scientific meetings of acknowledged medical societies.
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