719 - Acute Dyspnea in a 6-year-old Child: A rare presentation of Juvenile Myasthenic Gravis with Pre-pubertal Onset

6-year-old child initially admitted for inflammatory encephalitis vs hypoxic brain injury, seizures, and dyspnea in the setting of RSV infection. Six months later, re-admitted due to worsening dysphagia and fatigue which progressed to acute respiratory failure. Subsequently found to have anti-body positive Myasthenic Gravis.


Case Description:

6-year-old female initially admitted for seizures and found to have MRI findings of inflammatory encephalitis vs hypoxic brain injury, vision impairment, and dyspnea. Initial symptoms thought to be related to RSV infection.

Seen in clinic 3 months after admission and doing well. Then, when she was seen in clinic 6 months after initial admission, parents reported several months of visual and motor fatigue in addition to worsening dysphagia.  Dyspnea continued to progress and parents now observed dyspnea with strenuous activity. Lastly, she developed drooling while eating. She was subsequently re-admitted roughly 6 months after initial admission due to acute respiratory failure and required intubation. She was found to have positive acetylcholine receptor antibodies and diagnosed with Juvenile myasthenia gravis with pre-pubertal onset. 


Discussions:

Most reported cases of Juvenile myasthenia gravis are associated with ocular symptoms. However, in our case the visual impairment was less significant compared to dysphagia and respiratory symptoms. Interestingly, the ocular symptoms did not limit the patient’s overall function. The patient instead presented with severe bulbar symptoms; a finding more classically related to adult presentations of myasthenia gravis. In the evaluation of pediatric patients with dyspnea, it is vitally important for the physiatrist to perform a thorough review of systems and complete physical exam to pick up on subtle findings that may be related to more rare diagnoses such as Juvenile myasthenia gravis.


Conclusions:

In closing, the differential of pediatric patients presenting with dyspnea, visual changes, and functional limitations should include rare disorders such as myasthenia gravis.