Previous Medical Problems

I get so tired easily. Angelina, a35 year old female, with no previous medical problems, presented herself to her GP complaining that she gets tired very easily during the day. Questioning by her GP indicated that the problem started about ayear before, when she initially thought that the tiredness was due to the heavy work load she had at the time. However since then, her workload has decreased but the problem has remained and got worse. She reported that she was able to be active early in the day, but then got very tired as the day progressed. The tiredness was particularly enhanced following physical activity accompanied by general aches and pains. She said that ifshe had regular ‘rest periods ’then she could moderate the level of tiredness. Her GP carried out abasic health examination and found nothing remarkable, though he did notice that one of her eyes showed ptosis. Ablood sample was taken for laboratory analysis. Aweek later Angelina returned to her GP. The results from the blood sample analysis indicated raised levels of antibody to the acetylcholine receptor but not to the MuSK protein. Her GP referred her to aneurologist for further assessment, as well as for chest imaging. Neurological assessment by EMG recording and supramaximal nerve stimulation showed that motor and sensory nerve conduction velocities testing were normal. Pin prick and touch tests, along with stretch reflexes were normal also. Low frequency repetitive stimulation (3 Hz) of the nerve resulted in the EMG response ‘waning ’as successive stimuli were applied. The neurologist carried out aTensilon test and this resulted in arapid but short lived alleviation of her symptoms, particularly the ptosis. Functional imaging revealed no obvious damage to the central or spinal neural circuitry. Imaging of the chest area revealed an enlarged thymus, with no indication of lung cancer. In addition, amuscle biopsy was taken, and histological analysis indicated structural changes at the level of the neuromuscular junction. These tests helped to rule out certain neurological conditions whilst confirming the condition that the neurologist thought Angelina had. Following discussion between her neurologist and GP, itwas decided that to alleviate Angelina ’ssymptoms quickly that she should undergo plasma exchange therapy followed by drug therapy. Angelina said she could not undergo plasma exchange as this would go against her personal beliefs. Her GP tried to persuade her that the treatment was in her best interests but she still refused the plasma exchange. Her GP acquiesced to her position, and so started treating her with acourse of Pyridostigmine coupled with Propantheline. Initially, she showed improvements in her symptoms being functional daily without excessive tiredness. However 6 months later the symptoms were worse again. Following discussions with her GP and neurologist, Angelina agreed to have athymectomy despite her continued personal beliefs. Following the thymectomy she has been able to live anormal life. Post-operative examination of the enlarged thymus revealed itto be benign.