CASE STUDY 11 - Cecelia Pulaski

Cecelia Pulaski, age 27, noticed changes in her energy level accompanied by muscle weakness. Particularly when she swallowed, she would sometimes feel that food was stuck in her throat. She had difficulty combing her hair, and she noticed that her voice was very weak. The weakness would usually improve when she rested. She was admitted to the hospital for myalgia, paresthesia, and immobility of all extremities. At the time of admission, she was having difficulty breathing. She recently experienced an extremely stressful divorce.
On physical examination, Ms. Pulaski is unable to close her eyes completely. Her pupils respond normally to light and show normal accommodation. She has lost 15 pounds in the last month. Her tongue has several fissures. Her laboratory data are essentially normal except for a positive antibody test, which is indicative of an autoimmune disorder attacking muscle cells at the neuromuscular junction. Electrical testing of the neuromuscular junction shows some blocking of discharges. A pharmacological test using edrophonium chloride is positive. Edrophonium chloride inhibits the breakdown of acetylcholine at the postsynaptic membrane.