Objective: We report a unique case of a patient with concurrent myasthenia gravis and Parkinson’s disease, with a history of environmental exposure to organic solvents as at Camp Lejeune.

Background: Parkinson’s disease(PD) is the second most common neurodegenerative disorder. In contrast, myasthenia gravis(MG) is a rare autoimmune disorder. The co-occurrence of PD and MG has been rarely reported, and it remains unclear whether this uncommon phenomenon is incidental or etiologically related. In this case, the patient had toxic exposure at Camp Lejeune where trichloroethylene(TCE) and other volatile organic compounds contaminated the water supply. It was shown that the risk of developing PD was 70% higher in Veterans at Camp Lejeune, likely due to TCE which is also known to increase the risk of various neurological disorders including peripheral neuropathy.

Method: Two neurologists reviewed the history, physical examination, laboratory, and imaging studies of a Camp Lejeune Veteran who was seen at Hines VA neurology clinic.

Results: A 63-year-old male with a history of hypertension and dyslipidemia presented to the VA clinic with a constellation of neurologic symptoms including dizziness, hand tremors, and slowness of movement. The patient already underwent extensive workup at outside hospitals including brain and spine MRI, CSF studies, and genetic tests but all results were unremarkable. The examination was notable for parkinsonism, postural and kinetic tremor in both hands, hypesthesia to the level of the bilateral knees and elbows. He also reported new-onset fatigable weakness at the end of his shift. Serum MG antibody tests came back negative but EMG result with repetitive nerve stimulation test was consistent with MG. Skin biopsy showed small fiber neuropathy. The patient was started on pyridostigmine and levodopa which for his myasthenic symptom and asymmetric parkinsonism were responsive.

Conclusion: This case represents a unique co-occurrence of MG, PD and essential tremor, and small fiber neuropathy in a veteran at Camp Lejeune, where exposure to toxic organic solvents was documented. This case underscores the importance of recognizing environmental exposures as potential risk factors causing a rare combination of neurological disorders including MG and PD. More research needs to be done regarding the effects of environmental toxins on the development of co-incident neurologic conditions.

References: Goldman, Samuel M., et al. “Risk of Parkinson disease among service members at marine corps base camp Lejeune.” JAMA neurology 80.7 (2023): 673-681.
Dorsey, E. Ray, et al. “Trichloroethylene: An invisible cause of Parkinson’s disease?.” Journal of Parkinson’s Disease 13.2 (2023): 203-218.
Barragán-Martínez, Carolina, et al. “Organic solvents as risk factor for autoimmune diseases: a systematic review and meta-analysis.” PloS one 7.12 (2012): e51506.
Bove, Frank J., and Perri Zeitz Ruckart. “An Assessment of the Feasibility of Conducting Future Epidemiological Studies at USMC Base Camp Lejeune.” (2008).
Hirschey, Jacqueline, et al. “Categorizing Movement Disorders Associated with Toxic Exposures at Camp Lejeune Military Base (P5-11.003).” Neurology 100.17_supplement_2 (2023): 2501.

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