key: cord-0953833-ltdfbk4k
authors: Delly, Fadi; Syed, Maryam J.; Lisak, Robert P.; Zutshi, Deepti
title: Myasthenic crisis in COVID-19
date: 2020-07-15
journal: J Neurol Sci
DOI: 10.1016/j.jns.2020.116888
sha: 7f12da49588de3778cbe3540740d4ba680a1ca01
doc_id: 953833
cord_uid: ltdfbk4k

• Myasthenic crises is a potentially severe complication of COVID-19. • Hydroxychloroquine can aggravate myasthenia crises. • IVIg is a potential treatment for both Myasthenic crises and COVID-19. • IVIg treatment may cause thrombosis in susceptible patients.

The neurotropic potential and the neurological complications of coronavirus disease are still being uncovered, those documented so far include headaches, acute cerebrovascular incidents, anosmia, post-infectious disseminated and brainstem encephalitis and viral meningitis [1] and Guillain-Barré Syndrome [2] . Myasthenia gravis (MG) patients are particularly susceptible to infections causing crises due to the combination of reduced neuromuscular safety factors adversely affected by pyrexia and the effect of acute inflammatory mediators compounded by immunosuppression in many patients [3, 4] . Acute respiratory distress (ARDS) seen in COVID-19 coupled with respiratory muscle failure seen in MG crises may result in a dire prognosis. We present a case of a 56-year-old woman who developed MG crisis and concomitant COVID-19.

The patient is a 56-year-old woman with a history of acetylcholine receptor antibody (AChR-Ab) positive MG for over five years maintained on pyridostigmine 60 mg four times daily, prednisone 20 mg twice a day and intravenous immunoglobulin (IVIG) infusions (650 mg/kg for two days every two weeks). The patient had refused thymectomy. She also took hydroxychloroquine 200 mg twice daily for mixed connective tissue disease. Her exacerbations typically consisted of weakness of her lower extremities, ptosis and dysphagia but no history of mechanical ventilator support. She presented to the emergency department with dyspnea, fevers, rhinorrhea and diffuse myalgias. She had 70% oxygen saturation, was placed on 15 L of oxygen on non-rebreather but continued to deteriorate requiring mechanical ventilation. Initial chest x-ray showed bi-basilar infiltrates compatible with pneumonia ( Figure 1A) . She was started on vancomycin, cefepime, azithromycin and prednisone was increased to 40 mg twice We present this first known case in the literature of MG crises with simultaneous COVID-19.

Recent guidelines for the management of MG during the COVID-19 pandemic suggest individualized therapy, however, MG crises has not been addressed as a potential complication of COVID-19 [4] . While coronavirus infections have not been documented as a cause of MG crisis, viral infections in general have been reported to trigger autoimmunity through

Neurologic complications of coronavirus infections

Guillain-Barre syndrome related to COVID-19 infection

COVID-19 and neuromuscular disorders

Guidance for the management of myasthenia gravis (MG) and Lambert-Eaton myasthenic syndrome (LEMS) during the COVID-19 pandemic

Myasthenia gravis and infectious disease

Molecular immune pathogenesis and diagnosis of COVID-19

Treatment of myasthenia gravis based on its immunopathogenesis

Current status of potential therapeutic candidates for the COVID-19 crisis

Intravenous immunoglobulin-associated arterial and venous thrombosis; report of a series and review of the literature

Incidence of thrombotic complications in critically ill ICU patients with COVID-19