Graves' Disease Associated with Myasthenia Gravis: Report of One Case

葛瑞夫茲氏症合併重症肌無力：一病例報告

朱惠瑜(Hui-Yu Chu) ； 徐山靜(San-Ging Shu) ； 麥淑珍(Suk-Chun Mak) ； 遲景上(Ching-Shiang Chi)

《Acta Paediatrica Sinica》 33卷6期 (1992/12) Pp. 457-461

摘要

兒童葛瑞夫茲氏症的眼部病變，大多以突眼爲表現，很少有眼外肌肉痳痹、侵犯角膜或視神經的嚴重病變。英文文獻中關於兒童葛瑞夫茲氏症合併眼部重症肌無力的病例報告極少；成人的報告中，多數病例爲年輕女性，他們多先出現甲狀腺腫塊及功能亢進症狀，然後才出現眼瞼下垂之重症肌無力，常須使用藥物甚至手術治療。
本篇報告一位七歲女童，自五歲起即出現眼瞼下垂，經過不規則的治療，症狀時好時壞。兩年後陸續出現心悸、流汗、焦慮及甲狀腺腫塊，同時兩眼除了眼瞼下垂，出現突眼及眼外肌痳痹的現象。血清中甲狀腺素(Thyroxine)的濃度爲17.05 ug/ml；T3濃度爲496 ng/dl；甲促素(TSH)濃度小於0.1 uU/ml,流離甲狀腺素大於4.2 ng/dl。同時抗甲狀腺抗體皆陽性：ATA抗體爲1:25600，AMiA抗體爲1:102400，因經診斷爲葛瑞夫茲氏症。由於此病甚少合併眼瞼下垂，因此我們便作了Neostigmine試驗。給予肌肉注射Neostigmine後，病人眼皮可擡起且持續三十分鐘以上，確認她同時有眼部重症肌無力。經過抗甲狀腺藥物及Mestinon治療，其病況維持穩定狀態。
這兩種疾病同時出現，在兒童及青少年十分罕見，其致病因目前仍不清楚，許多學者認爲可能是相關免疫疾病，使病人體內同時存在有對抗甲促素接受器、胸腺、眼部肌肉組織，及Acetylcholine接受器之自體抗體所致。我們建議在葛瑞夫茲氏症病發現眼瞼下垂，應考慮重症肌無力同時存在的可能性；又在重症肌無力病人要定期監測其甲狀腺機能，及其他自體免疫疾病的發生，以為早期診斷及治療。

並列摘要

Exophthalmos occurs in more than half of the patients with childhood Graves' disease, while severe Graves' ophthalmopathy is uncommon in children. Myasthenia gravis is even more rare in association with Graves' disease. A 7-year-old girl is reported; she had ptosis for two years; this was treated irregularly, and she then developed exophthalmos, ophthalmoplegia and thyroid goiter. Her laboratory tests showed T3 496 ng/dl, T4 17.05 ug/dl, TSH ＜ 0.1 uU/ml, fT4 ＞ 4.2 ng/dl. Antithyroglobulin antibody was 1:25600 and antimicrosomal antibody was 1:102400. Myasthenia gravis was confirmed by a positive neostigmine test. Due to allergic reaction to propylthiouracil, she was treated with carbimazole and propranolol. Thereafter the thyrotoxicosis was was well controlled. The ocular-type myasthenia gravis remained stable with minimum medical treatment.

並列關鍵字

Graves' disease ； myasthenia gravis ； see-saw phenomenon ； autoimmune disease