POST-TRAUMATIC UNILATERAL PTOSIS-FOOTBALL 388

Abstract

HISTORY: A 17 year old Division I collegiate offensive lineman developed painless, partial left ptosis several hours after minor leftsided head trauma during a scrimmage. The finding-remitted overnight, only to recur as a complete ptosis during scrimmage the next morning. Thereafter, the ptosis fluctuated in severity, clearly worsening during heavy physical activity such as weight lifting. There were no other ophthalmologic, neurologic or general medical symptoms. Two years previous, he experienced transient diplopia for two days following an injury to the left temporal area during high school football practice. Two weeks later he developed painless, partial left ptosis for several weeks. A head CT was negative, the symptom remitted and he returned to play. PHYSICAL EXAMINATION: The detailed general and neurolgic examinations were normal except for the following: moderate obesity; left ptosis (palpebral fissures = 14mm OD. 9mm OS) without decrement on 1.5 min. sustained upgaze: positive left Cogan's lid twitch: no evidence of Horner's syndrome. DIFFERENTIAL DIAGNOSIS: Myasthenia Gravis Rare myasthenic-like response seen with low grade, slow growing periorbital neoplastic or vascular lesions involving nerves to the extraocular muscles. TEST AND RESULTS: Hb 133 g/l with normochromic, normocytic indices. CXR. SPEP, TFTs, nicotinic acetylcholine receptor antibodies, Tensilon test, IM Prostigmine test = normal or negative. Electrophysiologic studies: significant decremental response on 2-4 Hz repetitive nerve stimulation to left trapezius. FINAL/WORKING DIAGNOSIS: Myasthenia Gravis. TREATMENT: No contact. OK to exercise. Daily weight, BP. No response to oral mestinon. Transient decremental response of deltoids and neck flexors several hours after strenuous physical activity. Prednisone 60mg qod, with slow taper over months. Symptomatic remission within 6 weeks of starting prednisone. Should he play collegiate football in the future?