Tobias Kulik, MD
Assistant Professor of Neurology
University of New Mexico Hospital
Albuquerque, New Mexico, United States
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Title: An unusual case of eyelid ptosis
Case Report Body:
Introduction: Classically, subacute onset of painless, eyelid ptosis in the middle aged population has been associated with a neuromuscular junction disorder, for example Myasthenia Gravis (MG) or Lambert-Eaton syndrome (LES). However, more recently, esoteric causes of ptosis and weakness have made a come back that are important to consider to tailor therapy adequately. We report on a patient who presented with unilateral eyelid ptosis and mild upper extremity weakness where the ultimate diagnoses was made in time to administer life saving treatment.
Description: A 57 year-old right-handed man presented to our Emergency Department with a two day course of worsening left eyelid ptosis, generalized fatigue and shortness of breath. On further questioning, he reported that he had noticed his ptosis to worsen at the end of the day or when fatigued. One day prior to arrival, he noticed difficulties swallowing and was ‘choking on food’. In addition, he developed generalized weakness and fatigue and had difficulties ‘catching his breath’. He denied a history of similar episodes, denied recent sickness or fever. He was admitted to our Neuroscience ICU given a concern for impending respiratory failure and MG crisis. In the absence of a prior history of MG, a thorough work up was initiated. Initially, he was started on IVIG infusions, however, his symptoms continued to worsen and no improvement was noted. With more detailed history taking and a thorough neurological exam, the diagnosis of MG was questioned. When the patient reported use of black tar heroin, tested for botulism was initiated. With a confirmatory result, he was administered botulism antitoxin which lead to a prolonged recovery.
Discussion: Recently, there have been multiple cases of reported botulism in middle aged users of black tar heroin, particular in the SouthWest. It is important to consider botulism in a patient who presents with new onset ptosis or patchy weakness and start the appropriate workup and treatment without delay.