Ivani Proano, DO
PGY-2
Rutgers University- Kessler Institute for Rehabilitation
Newark, New Jersey, United States
Grace F. Suttle, MD
Brain Injury Fellow
Rutgers Health/Kessler Insitute for Rehabilitatin
Newark, New Jersey, United States
Jennifer Russo, MD
Associate Brain Injury Medicine Fellowship Director
Rutgers/Kessler Institute of Rehabilitation
Saddle Brook, New Jersey, United States
Vertigo and generalized weakness are common complaints in physical medicine and rehabilitation settings, typically managed by addressing musculoskeletal and vestibular etiologies. However, when standard treatments fail, clinicians must broaden the differential diagnosis to include neuromuscular disorders.
Case Description:
A 26-year-old female with a medical history of hypertension and chronic vertigo presented with worsening dizziness, generalized weakness, calf pain, and ambulatory limitations following an initial rehabilitation course. Despite symptomatic treatment with meclizine, she experienced a progressive decline in functional status. Neurological examination revealed persistent horizontal nystagmus and lid lag. Repeated vestibular assessments, including the Dix-Hallpike maneuver, were negative for benign paroxysmal positional vertigo (BPPV), and imaging studies, including a CT scan of the head, were unremarkable. Her progressive functional decline and refractory symptoms prompted the pursuit of neuromuscular workup. Although serology and repetitive nerve stimulation tests were negative, single fiber electromyography (SFEMG) demonstrated increased jitter, confirming a diagnosis of myasthenia gravis.
Discussions:
: Given her refractory symptoms and ocular findings, myasthenia gravis (MG) was considered and later established based on SFEMG findings, as this test is the most sensitive for detecting myasthenia gravis. The patient responded well to pyridostigmine, showing marked improvement in both her symptoms and functional capacity.
This case underscores the importance of broadening the differential in patients with vertigo and functional decline that does not respond to standard treatments. Myasthenia gravis may present with atypical symptoms, such as refractory vertigo, and require advanced neuromuscular testing like SFEMG for diagnosis.
Conclusions: Myasthenia gravis should be considered in patients with unexplained weakness and vertigo, particularly when conventional diagnostics are inconclusive. This case illustrates the value of SFEMG and the potential for positive outcomes with prompt, targeted treatment.
