{
  "abstract": "A functionally-independent patient in their 50s, with a history of personality disorder and alcohol-excess, attended A&E having fallen down the stairs. CT Head revealed bilateral small-volume subarachnoid and cortical haemorrhage, and a fractured right temporal bone. They were discharged after a period of observation.After repeated attendances to ED, they were re-admitted 5 weeks after first presentation – following progressive functional decline in the community, requiring QDS care. Examination revealed bilateral ptosis, complex ophthalmoplegia and fatigable bilateral upper/lower limb weaknessA diagnosis of probable Myasthenia Gravis was established on first Neurology review, 41 days after initial presentation; demonstrating clinical improvement with steroids and pyridostigmine. Diagnosis was confirmed by AChR antibodies and electromyography demonstrating decrement on repetitive stimulation.Trauma, as in this case, can be a precipitant of myasthenic crisis or in rare cases the underlying aetiology. Other precipitants of myasthenic crises include medications, infections, surgery, pregnancy.When initial diagnosis is at odds with symptom progression it necessary to consider alternative differentials. Diagnostic overshadowing refers to the misattribution of symptoms to pre-existing, typically psychiatric, conditions. In this case, the trauma-related diagnoses and antecedent psychiatric history obfuscated the patient’s progressive symptoms and ultimate diagnosis, resulting in significant functional impairment and delayed care.f.vansomeren@nhs.net",
  "authors": [
    {
      "affiliations": [
        "Lister Hospital, Stevenage"
      ],
      "name": "van Someren Frederick"
    },
    {
      "affiliations": [
        "Lister Hospital, Stevenage",
        "Royal Free Hospital, London"
      ],
      "name": "Kock Norman"
    }
  ],
  "title": "166 Diagnostic overshadowing in acute neurology: a case of post-traumatic myasthenia gravis",
  "uid": "69decb56-dfb0-516c-b1a3-2f4c1c2d930c"
}