Objective: To examine a case of acute, simultaneous presentation of Parkinson’s disease (PD) and Myasthenia Gravis (MG).

Background: PD is a neurodegenerative disease characterized by bradykinesia, tremor, rigidity, and postural instability. Hallmark signs of MG- an autoimmune disorder targeting the neuromuscular junction (NMJ)-include: fatigable muscle weakness, diplopia, and dysphagia. Though cases of coexisting PD and MG are reported, we present a unique case of rapid-onset symptomatology leading to simultaneous diagnoses.

Methods: An 84 year-old male with hypothyroidism presented with a two-week course of rapidly progressive dysphagia requiring PEG placement. In the following month, he developed hypophonia, fatigue, exercise intolerance, gait impairment, and a mild, infrequent, asymmetric, bilateral resting hand tremor. He also reported new micrographia, stooped posture, and one fall. The patient, his family members, and his primary physician separately confirmed that he was completely independent and well prior to dysphagia onset. No relevant personal, family, or social history. On presentation to our institution, exam was notable for: bilateral ptosis; marked hypophonia; rigidity in bilateral upper and lower extremities without axial rigidity; 5/5 strength; moderate generalized bradykinesia; resting chin and bilateral hand tremor, right greater than left; and postural instability.

Results: DaT Scan showed near absent radiotracer uptake in bilateral putamen and decreased uptake in left greater than right caudate. He experienced significant and immediate improvement of rigidity, bradykinesia, and tremor with carbidopa-levodopa. EMG/NCS with repetitive nerve stimulation showed a significant, decremental response in the facial nerve, suggestive of MG. Positive acetylcholine receptor antibodies confirmed MG diagnosis; further imaging was negative for neoplasm. Pyridostigmine and corticosteroids led to significant improvement in dysphagia and fatigue; patient is again independent in all daily activities and tolerates normal diet.

Conclusions: Rapid-onset parkinsonism with severe dysphagia is rare. While early and severe dysphagia is seen with PSP, this patient’s age and history were inconsistent with that diagnosis. We must remain vigilant to identify potential concomitant diagnoses clouding the presentation of common movement disorders, as timely diagnosis and treatment can significantly improve function and quality of life.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/simultaneous-symptomatic-onset-of-parkinsons-disease-and-myasthenia-gravis/