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Hickam's dictum: Myasthenia Gravis presenting concurrently with Graves' disease
  1. Shekhar Sehgal1,
  2. Roshan Rebello1,
  3. Louise Wolmarans1,
  4. Marianne Elston1,2
  1. 1Department of Endocrinology, Waikato Hospital, Hamilton, New Zealand
  2. 2Department of Endocrinology, Waikato Hospital, Hamilton, New Zealand
  1. Correspondence to Dr Shekhar Sehgal, shrike59{at}


We present two patients with Graves’ disease and concurrent myasthenia gravis. The impact of the dual diagnosis on the clinical course and the potential for a delayed diagnosis of myasthenia gravis is discussed. Patient 1, a 28-year-old man was diagnosed with Graves’ disease following his second respiratory arrest. His history was strongly suggestive of a second pathology. Patient 2, a 66-year-old Cantonese woman with established Graves’ disease presented with thionamide-related neutropaenia. Examination revealed bilateral ptosis and right lateral rectus palsy. Both patients had thyrotoxicosis secondary to Graves’ disease with concurrent myasthenia gravis. Although neuromuscular weakness is common in Graves’ disease, coexisting myasthenia gravis (MG) is rare and can cause profound morbidity. Ocular signs in both diseases may cause diagnostic confusion although ptosis suggests coexisting MG. In both cases, the thyrotoxicosis delayed the diagnosis of MG.

  • muscle disease
  • thyroid disease

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  • Contributors SS and RR contributed equally to authorship, ME and LW reviewed the paper and provided clinical supervision.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.