ABSTRACT
Purpose: The aim is to review immunological triggers as well as beneficial treatment regimens and their considerations in managing Myasthenia Gravis patients with varying severity of COVID-19. Methods: A systematic review was performed on 63 articles through an extensive search of PubMed, Science Direct, Google scholar, JAMA, and Scopus databases from the onset of COVID-19 to date using keywords, 'COVID-19,' 'Myasthenia Gravis,' 'Neuromuscular disease,' 'Immunosuppressants,' and 'Immunomodulators.' We excluded other neuromuscular disorders and included 18 articles of COVID-19 patients with Myasthenia Gravis. No exclusions were made for age, sex, or geographical regions. Results: During this COVID-19 pandemic, we need to be watchful for neuromuscular complications that may be directly or indirectly related to coronavirus infection. Coronavirus, through molecular mimicry, forms autoantibodies against the neuromuscular junction that might trigger immune-mediated disorders such as Myasthenia Gravis (MG). MG patients on immunosuppressive or immunomodulatory therapy are predisposed to COVID- 19, manifesting severe complications. Steroids have varied effects on COVID-19 patients depending on their stage of infection, not effective in earlier infection but beneficial in ARDS by inhibiting chemokine production. IL-6 is an inflammatory marker found in COVID-19 and MG patients, which can be associated with a higher mortality rate. Experimental therapies for COVID-19, such as combined use of azithromycin and hydroxychloroquine, may trigger a myasthenic exacerbation or crisis. Hydroxychloroquine is known to result in potential neuromuscular side effects. Diaphragm hemiparesis was possibly induced secondary to the myasthenic crisis in the setting of a viral illness and azithromycin's recent use. Conclusions: Routine treatment for MG should be tailored depending on the COVID-19 severity. Steroids and immunomodulators should be used with caution in MG patients. However, limited data exist on how COVID-19 affects people with Myasthenia Gravis.
ABSTRACT
Background: An unprecedented global effort in identifying potentially viable and emerging drugs for effective treatment of the novel coronavirus disease (2019) is being made. Of the most promising candidate therapies, convalescent plasma (CP), albeit controversial, is approved for emergency use authorization (EUA) by the U.S. Food and Drug Administration (FDA). The concept rests on passive immunity, achieved by administering plasma with high titers of neutralizing antibodies to reduce severity of SARS-CoV-2 infection and mortality. The aim of this paper is to assess the clinical improvement, patients' discharge status and all-cause mortality in convalescent plasma versus standard of care COVID-19 patient groups. Methods: Using PRISMA guidelines, a review was conducted from January, 2020, until October, 2020 employing keywords including "convalescent plasma", "clinical improvement, "mortality", "adverse events", "viral load", "dosing", and survival." Dichotomous data for all-cause mortality, patients' discharge status, and clinical improvement at day 14 of treatment were meta-analyzed applying the Mantel-Haenszel (M-H) random effects model using Review Manager 5.4. Results: A total of 627 (23.9%) patients in the CP group and 1997 (76.1%) patients in the control group were pooled. The studies were conducted in the United States, China, Netherlands, and Iran. The CP group had a lower association to all-cause mortality as compared to the control group [OR: 0.69;CI: 0.50 to 0.96;P=0.03]. Patients who received CP had higher probability of discharge during the study course [OR: 1.87;CI: 1.1 to 3.18;P=0.02]. Bias was expected in the analysis due to the stratified of study designs included. Conclusion: Convalescent plasma therapy may be an effective and vital tool with promising historical, current, and expected clinical trial evidence of metrics such as increased safety and reduction of all-cause mortality.