Eyes and Bowels Bottled Up - Abstract

A 56 year-old man presented with diplopia and ptosis. Actually he was more concerned about severe constipation that had started about the same time. Abdominal x-rays had shown stool loading; laxatives had been ineffective. Our exam showed bilateral ptosis with complete ophthalmoplegia in both eyes. Pupils were normal, as was the rest of the ophthalmic examination. He had mild hypophonia but an otherwise normal neurologic exam, including intact muscle stretch reflexes. Acetylcholine receptor antibody titers were abnormal: binding 6.39 nmol/L (normal < 0.02nmol/L), striational 1:30270 (normal < 1:60), modulating 95% loss of function (normal 0-20%). To investigate his constipation, we performed abdominal CT, which showed dilated loops of small bowel without apparent obstruction. Within days of starting treatment with pyridostigmine (60mg 5x/day), his constipation was relieved, and CT showed resolution of the dilated bowel loops. But his eye signs persisted