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Background
In a limited resource setting, edrophonium/neostigmine tests are still preferred over ice pack test even though former has ominous complications and latter being equally effective in diagnosis of myasthenia.
Ice pack test can be performed bed side without any special equipment in a non-ICU set up with nil complications if correctly performed.
Case presentation
A 40-year-old male presented with progressive fatigue over past 3 months. For past 1 month, the patient noticed that he had intermittent double vision which improved in the morning. He developed drooping of both eyelids since 10 days. Further inquiry highlighted that these symptoms were worse after watching television and at the end of the day. He also had difficulty in eating, especially non-vegetarian food, which according to him was difficult to swallow.
Neurological examination of the patient revealed that he had bilateral ptosis( 3 mm palpebral fissure in left eye and 5 mm in right) with some fatigability. Extraocular movements were restricted in all directions to various degrees in both eyes not confined to a particular nerve distribution. There was no squinting in primary position of the eye. No nystagmus was present but he had interrupted saccades. Pupils were normal in size and reacting equally to light. Though he had difficulty in swallowing there was no objective cranial nerve abnormality detected. There was no discernable dysphagia (assessed by speech and language therapy services) or dysphonia, and his cough effort was normal. His single breath count...