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A 40-year-old man presented with slowly progressive weakness and eyelid droopiness. His symptoms began in his early 30s as increased fatigue with exertion. In his mid 30s, he developed droopy eyelids without double vision. About 3 years before presentation, he started having progressive difficulty swallowing, initially with solid food but later with both solid and liquid consistencies. He also reported the food getting stuck in his throat. He had been treated for aspiration pneumonia once. A year later, he noticed slowly progressive limb weakness affecting his hands and proximal lower limbs, described as difficulty holding a tablet at church, frequently dropping objects from his hands, and difficulty with standing up from a seated position. More recently, he started experiencing dyspnea on exertion and mild orthopnea. He occasionally experienced blurry vision without diplopia, mild head drop, and hoarseness of voice, mainly towards the end of the day or when he was tired. He was diagnosed with seronegative myasthenia gravis at a local facility, with negative acetylcholine receptor, muscle-specific kinase, and low-density lipoprotein receptor-related protein 4 antibodies. His medical and social history were otherwise unremarkable. The patient's father was French Canadian. The patient also had Native American and African American ancestry. There was no family history of myopathy or any neuromuscular disorder. Neurologic examination was significant for moderate bilateral ptosis, bilateral ophthalmoparesis with limited upward gaze and to a lesser extent horizontal gaze (both eye abduction and adduction), mild weakness of both upper and lower facial muscles, moderate weakness of the proximal lower extremities most prominent at the hip abductors (Medical Research Council [MRC] grade 3 to 4-/5), and mild (MRC grade 4) weakness of finger extensors and intrinsic hand muscles. He had no demonstrable fatigable weakness on examination in any of the affected muscles. He had a mildly waddling gait and absent ankle jerks bilaterally. Sensory and coordination evaluations were unremarkable.

Clinical Reasoning: Bilateral ptosis, dysphagia, and progressive weakness in a patient of French-Canadian background