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Educational objective: lvlyasthenia gravis is caused by autoantibody-mediated degradation of acetylcholine receptors at the neuromuscular junction, which often leads to fatigable ocular and bulbar muscle weakness. Most patients with acetylcholine receptor antibodies have thymic abnormalities (eg, thymoma, thymic hyperplasia), which appear as an anterior mediastinal mass on chest imaging.

A 38-year-old woman is evaluated in the clinic due to swallowinq problems that began 1 month ago while eating dinner. Halfway through the meal, she had difficulty chewing her steak and was unable to swallow it Since then, the patient has had 2 similar episodes associated with food and water regurgitation through her nose. She has a history of gastroesophageal reflux disease and a meningioma that was resected 4 years ago. The patient uses omeprazole and over-the-counter eye drops as needed. She has smoked a half pack of cigarettes daily for 16 years and drinks 1 to 2 glasses of wine daily. Her blood pressure is 138/76 mm Hg and pulse is 82/min. Oropharyngeal examination is unremarkable. Lung auscultation is normal. Heart sounds are normal with no murmurs. The abdomen is soft and nontender with no organomegaly. She has no focal weakness or sensory loss, and reflexes are normal. Upper gastrointestinal endoscopy and esophageal manometry are normal. CT scan of the chest is shown below.

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Educational objective: Myasthenia gravis is characterized by fluctuating, fatigable muscle weakness that worsens with repetitive motions and improves with rest Common symptoms include weakness of the proximal (eg, difficulty rising from sitting), ocular (eg, diplopia, ptosis), and bulbar (eg, dysarthria, dysphagia) muscles. Pregnant and postpartum patients are at increased risk for developing the disease.

A 28-year-old woman comes to the office due to weakness. The patient, who is 8 weeks postpartum, reports intermittent weakness of the upper and lower extremities. She says, "11/ly arms feel weak after carrying the baby for a few minutes, and I can't lift him until I rest for some time. Yesterday evening, I couldn't even get off of the toilet, but today, I feel fine." The patient has also had episodes of blurry vision. Her pregnancy was complicated by gestational diabetes, but she has no chronic medical conditions. The patient's only medication is a daily multivitamin. She does not use tobacco, alcohol, or illicit drugs. Blood pressure is 120/68 mm Hg and pulse is 74/min. Physical examination shows normal pupils and extraocular movements. Jugular venous pressure is not elevated, and chest auscultation reveals no abnormalities. There is no extremity edema. Deep tendon reflexes and muscle strength of the bilateral upper and lower extremities are normal.

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Educational objective: Because the facialfophthalmic venous system is valveless, uncontrolled infection of the skin can result in cavernous sinus thrombosis. Red-flag symptoms include severe headache; bilateral periorbital edema; and cranial nerve 111, IV, V, and VI deficits .