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Positive AChR Antibodies: Presymptomatic MG or Red Herring?
I was referred a 70 yo non-diabetic man by a neuro-ophthalmologist for vertical diplopia who in the course of his workup was found to have positive AChR antibodies. The patient woke-up with isolated fixed binocular diplopia, has had no fluctuation since onset, and has no ptosis, fatiguability, or generalized weakness on exam. MRI of the brain was normal. Repeat MRI and AChR antibodies two months later were unchanged (normal and positive, respectively). No response to pyridostigmine. Interestingly, his brother has symptomatic MG with positive antibodies, diagnosed >20 years ago.
Given the history and exam, the working diagnosis is an MRI-negative posterior circulation stroke. But what to do about the antibodies? Pre-symptomatic MG? Epiphenomenon of underlying autoimmunity?
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Daniel Dumitru, MD, PhD