Delay and misdiagnosis in adult myasthenia gravis: A case report

Myasthenia gravis (MG) is a rare autoimmune disorder characterised by fluctuating and variable combination of muscle weakness and fatigue. Most cases are due to T-cell mediated autoantibodies against post-synaptic acetylcholine receptors (AChR-Ab), thus preventing acetylcholine from binding and signalling skeletal muscle to contract. 1 The annual incidence is 7-23 new cases per million. 1 It can occur at any age but with two peaks; an early- onset (20-40 years) female-predominant and a late-onset (60-80 years) male-predominant peak. MG is classified into ocular and generalised (80%). More than half the patients initially present with ptosis and diplopia but half will progress to generalised disease with involvement of bulbar, limb and respiratory weakness. Those presenting as generalised MG can also develop eye signs later. 1 It is important to recognise MG early because it is highly treatable. Untreated disease leads to permanent weakness. 2 Treatment reduces mortality from life- threatening myasthenic crisis. 1,3 Misdiagnosis leads to potentially harmful interventions and inappropriate management. 4,5 Diagnosis in late-onset MG is easily missed 2,3,4,5 because of overlapping symptoms with other diseases common in the elderly. We report a case of delay and misdiagnosis in an elderly patient with co-morbidities.

TB Meningitis (TBM): An Important Problem Which Should Not be Neglected in Laos! / Lao Medical Journal

Tuberculosis (TB) is an infectious disease commonly found in both developing and developed countries. Tuberculosis meningitis (TBM) is a serious central nervous system infection with a high mortality rate despite anti-TB drug treatment and is associated with HIV/AIDS. The diagnosis of TBM is difficult since the clinical aspects of the disease are similar to other central nervous system infections, examination for AFB in cerebrospinal fluid (CSF) stained with Ziehl-Neelsen is not sensitive and culture of Mycobacterium tuberculosis from CSF takes too long to influence initial therapy. Delayed diagnosis and treatment of TBM results in high mortality and disability. We report a Lao patient who had pulmonary TB in combination with TBM (confirmed by positive AFB in a sputum examination and a positive culture of Mycobacterium tuberculosis in the CSF) whose diagnosis and treatment were delayed resulting in serious nervous system sequelae and disability which may not be easily reversible. We discuss TBM diagnosis and use of simple clinical and laboratory features and suggest a low threshold for empirical treatment with anti-TB drug in case of suspected TBM.

Reasons for delayed diagnosis of ankylosing spondylitis in Chinese / 中华风湿病学杂志

Objective To investigate the reasons for delayed diagnosis of ankylosing spondylitis(AS) in a Chinese population.Methods Three hundred and eight patients fulfilled the 1984 Modified New York criteria of AS were enrolled.They were interviewed in person or by telephone by rheumatologists for 13 ques-tions.Results Of the 308 AS patients.238(75%)completed 13 questions.Among these 238 patients,male to female ratio was 6 to 1.The average age at AS onset was 22.1 years.Those aged under 15 years at disease onset Was 18.1%.and between 15 and 39 years was 79.0%while over 39 years was 2.9%.Of these 238 pa-tients.27(23.9%)had family history of AS.84.9% of the patients were HLA-B27 positive.The average dura-tion of delayed diagnosis in HLA-B27(+)and HLA-B27(-)were 70.1 and 88.1 months respectively,which was not significant statistically.Among those delayed over 10 vears,24 AS patients were HLA-B27(+)and 10 were HLA-B27(-),which was statistically significant(P=0.012).66.4% of 238 patients were misdiagnosed, of which 23.4%were diagnosed as arthritis associated with rheumatic fever,22.9% as fatigue and 20.3%as inter-vertebrate disc.45.0%were misdiagnosed by one physician while 2 1.4%were misdiagnosed for several times,and the average length of delay diagnosis was 72±68 months.Seven cases,although the diagnosisi was being delaved for more than 10 years the initial diagnosis was correct. Conclusion Delayed diagnosis of AS is common in China.The major reasons for delayed diagnosis are HLA-B27 negative and lack of X-ray changes of sacroiliac joint at the initial visit.