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Myesthenia Gravis (MG) is a neuromuscular disorder characterized by weakness and fatigability of skeletal muscles. The underlying defect is a decrease in number of available acetylcholine receptors (AChRs) at neuromuscular junction due to an antibodymediated autoimmune attack. Case Report: A 26 year old male patient from Dhar (M.P.), a tribal district, presented to civil hospital Ahmedabad (CHA) with complaints of unable to drink water since 5 months. Patient complained of water coming out from nose. Gradually he developed inability to eat also, with no evidence of vomiting.2 months later patient developed slurring of speech which was followed by total inability to speak. Along with that he developed diplopia on binocular vision. No such symptoms in siblings were there. On examination general examination was normal. On CNS examination he was conscious oriented with normal planter and deep tendon reflexes. On cranial nerve examination 3, 7, 9, 10th nerve palsies seen in the form of absence of medial & upward movement of left eye (3rd), inability to close eyes completely (3rd), reduced power and tone of buccinators muscle (7th), gag reflex absent (9th), presence of dysphagia (10th). Rest of the CNS findings were normal. He was given ryle’s tube feeding and investigated.CBC, LFT, RFT, urine routinemicro were normal.CSF examination showed mild increase of protein.MRI brain was normal. Vitamin B12, TSH, Calcium, HbA1c, ESR, RA factor were normal.ANA was (+) with nuclear speckled pattern. Fundus examination was normal with abnormal ocular movement as described.VEP study was normal.EMG NCV showed reduced amplitude of bilateral facial nerve, involvement of right oculomotor nerve suggesting bulbar myasthenia >generalized myasthenia. Then we did AChR antibody test which came highly positive. He was started T.Pyridostigmine 60mg TDS and T. Prednisolone 5mg/kg and discharged. On follow up we found marked improvement of symptoms. Conclusion: The present case shows that it is important to consider MG even in cases presenting solely with progressive bulbar palsy without easy fatigability.

A Case of Myasthenia Gravis Presenting Solely with Bulbar Palsy not associated with Easy Fatigability