Myasthenic crisis following SARS-CoV-2 infection and delayed virus clearance in a patient treated with rituximab: clinic
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LETTER TO THE EDITORS
Myasthenic crisis following SARS‑CoV‑2 infection and delayed virus clearance in a patient treated with rituximab: clinical course and 6‑month follow‑up Julia V. Wanschitz1 · Manuela Kaml1 · Bettina Pfausler1 · Raimund Helbok1 · Sophie Wildner2 · Gerlig Widmann3 · Sabina Sahanic2 · Florian Deisenhammer1 · Wolfgang N. Löscher1 · Markus Reindl1 · Judith Löffler‑Ragg2 · Ronny Beer1 Received: 9 September 2020 / Revised: 27 October 2020 / Accepted: 8 November 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Dear Sirs, Novel Corona Virus Disease 2019 (COVID-19) poses an unpredictable risk for patients with myasthenia gravis (MG) due to potentially additive effects of bulbar and respiratory muscle weakness and viral lung affection [1]. MG manifestations in conjunction with COVID-19, reported since the outbreak of the pandemic, were highly variable [2] and ranged from isolated ocular symptoms [3] to severe exazerbations with respiratory failure [1, 4, 5] and lethal outcomes of approximately 30% have been reported in a recent series of 15 consecutive patients [6]. Maintenance of standard immunosuppressive treatment is recommended in mild-tomoderate disease [7]; however, information about the management and outcome of patients with severe generalized MG treated with immune-depleting agents such as rituximab is still limited. We report the clinical course and 6-month follow-up of a 71-year-old female patient with exacerbation of AChRantibody positive MG following SARS-CoV-2 infection. MG was diagnosed in November 2018 when the patient presented with dysarthria and swallowing difficulties. Relevant co-morbidities included hypothyreosis and arterial hypertension. A global respiratory insufficiency in January 2019 required mechanical ventilation and intravenous treatment with neostigmine, steroids, and immunoglobulins (IVIg). * Julia V. Wanschitz julia.wanschitz@i‑med.ac.at 1
Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
2
Department of Internal Medicine II, Medical University of Innsbruck, Innsbruck, Austria
3
Department of Radiology II, Medical University of Innsbruck, Innsbruck, Austria
Oral pyridostigmine and steroids were maintained following extubation. Azathioprine was only given short-term because of liver toxicity. Despite two additional courses of IVIg, disease control was inappropriate and treatment with rituximab was initiated in July 2019; the last dose (1000 mg) was given in January 2020 resulting in significant clinical improvement (MG-ADL score 3) and reduction of steroids to 4 mg per day. In the beginning of March 2020 she developed mild symptoms of an upper respiratory tract infection with fever, cough, and arthralgia. A nasopharyngeal (NP) test was positive for SARS-CoV-2 RNA and she was placed in home quarantine for 2 weeks during which flu-like symptoms regressed. Four weeks after onset of COVID-19, she noted deterioration of her myasthenia with head drop, bulbar symptoms, dyspnea, and mild proximal
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