New onset of ocular myasthenia gravis in a patient with COVID-19: a novel case report and literature review
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New onset of ocular myasthenia gravis in a patient with COVID‑19: a novel case report and literature review Shitiz Sriwastava1 · Medha Tandon2 · Saurabh Kataria3 · Maha Daimee4 · Shumaila Sultan1 Received: 6 September 2020 / Revised: 4 October 2020 / Accepted: 7 October 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract The novel coronavirus outbreak of SARS-CoV-2 first began in Wuhan, China, in December 2019. The most striking manifestation of SARS-CoV-2 is atypical pneumonia and respiratory complications; however, various neurological manifestations are now well recognized. Currently, there have been very few case reports regarding COVID-19 in patients with a known history of myasthenia gravis. Myasthenia gravis (MG) causes muscle weakness, especially respiratory muscles, in high-risk COVID-19 patients, which can lead to severe respiratory compromise. There are few reported cases of severe myasthenia crisis following COVID-19, likely due to the involvement of the respiratory apparatus and the use of immunosuppressive medication. We report the first case of ocular MG developing secondary to COVID-19 infection in a 65-year-old woman. Two weeks prior to hospitalization, the patient suffered from cough, fever, and diarrhea and was found to be positive for COVID-19 via a nasopharyngeal RT-PCR swab test. The electrodiagnostic test showed decremental response over more than 10% on repetitive nerve stimulation test of orbicularis oculi. She tested positive for antibodies against acetylcholine receptor. COVID-19 is known to cause the release of inflammatory cytokines, leading to immune-mediated damage. MG is an immune-mediated disorder caused by molecular mimicry and autoantibodies against the neuromuscular junction. Keywords SARS-CoV-2 · COVID-19 · Myasthenia gravis · Ocular myasthenia · Neuromuscular disorder Abbreviations COVID-19 Coronavirus infectious disease 2019 gMG Generalized myasthenia gravis MG Myasthenia gravis oMG Ocular myasthenia gravis Anti-MuSK Anti-muscle-specific tyrosine kinase AchRs Acetylcholine receptor MERS Middle East respiratory syndrome SARS-CoV-2 Severe acute respiratory distress syndrome coronavirus 2 IDSA/ATS Infectious Disease Society of America/ American Thoracic Society * Shitiz Sriwastava [email protected] 1
Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, One Medical Center Dr., Suite 1310, Morgantown, WV 26506‑9180, USA
2
Safdarjung Hospital, New Delhi, India
3
Department of Neurology, University of Missouri Healthcare at Columbia, Columbia, MO, USA
4
Department of Neurology, MedStar Georgetown University, Washington, DC, USA
IVIG Intravenous immunoglobulin IL Interleukin EMG Electromyography MRI Magnetic resonance imaging RT-PCR Reverse transcriptase polymerase chain reaction CRP C-reactive protein
Introduction Myasthenia gravis (MG) is a common autoimmune disorder caused by the production of autoantibodies against nicotinic acetylcholine receptors at the neuromuscula
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