my dad in law is a 72 year old,hypertensive,diabetic,has a cosmetic eye on the right and has glaucoma on the left. he is on ramipril 2.5mg+s(-)amlodipine 2.5mg OD and glimeperide 2mg+acarbose 25mg+ Rosiglitazone 2mg+Metformin 500mg spaced during the day. there is a good control of BP as well as sugars.
about 45 days back he developed ptosis of both eyelids with improvement in the morning and worsening during the course of the day. otherwise he had symptoms of fatigue, weakness and occasional headache.
he was investigated for ptosis, which showed, a weakly positive neostigmine test, AchR antibodies assay(14) positive, Mild elevation of TSH, normal CT chest and MR brain.repetitive nerve stimulation showed no increment or decrement at 3,5,8 pps.clinical examination was unremarkable except for the ptosis.search for an unknown primary was futile.
he was since started on
pyridostigmine 60mg 4 times daily
thyroxine 25 mcg daily
along with his usual medications
presently he has no improvement in his ptosis although his weakness has disappeared. occasionally he has stammering when he talks rapidly.
now do i look for other diseases, or add immunosuppressants or give immunoglobulins?
would mycophenolate give an advantage over azathioprine?
given his age and concomitant illness what would be the best possible solution?
thank you for your answer