New acute onset of ocular myasthenia gravis after COVID-19 vaccine: A case report.

Reports have shown the association of coronavirus disease 2019 (COVID-19) with several neuromuscular disorders. Myasthenia gravis (MG) is an autoimmune disease in which antibodies bind to acetyl choline receptors in the postsynaptic membrane at the neuromuscular junction. The characteristic clinical feature of the disease is weakness of the ocular muscle, bulbar muscle, and extremity muscles; when the weakness is limited to the ocular muscle only, the condition is known as ocular myasthenia gravis. Diagnosis is usually confirmed by the acetylcholine receptor antibodies. Symptoms of MG may be aggravated by various types of infections and medications. Here, we are presenting a rare case of a new and acute onset of ocular MG presented after administration of Covishield vaccine.

COVID-19 Vaccination and Late-Onset Myasthenia Gravis: A New Case Report and Review of the Literature.

Myasthenia gravis (MG) is a rare autoimmune disease that is potentially threatening for patient life. Auto-antibodies targeting structures of the neuromuscular junction, particularly the acetylcholine receptor (AchR), are often found in the serum of MG patients. New-onset MG after SARS-CoV-2 vaccination has rarely been reported since the introduction of vaccination. Infections and COVID-19 infection have also been reported as possible triggers for a myasthenic crisis. We report a case of new-onset MG after receiving the mRNA COVID-19 vaccination. The patient was a 73-year-old male initially presenting with ocular symptoms and a rapid generalization. We also performed a literature revision of 26 described cases of MG after SARS-CoV-2 immunization. The patients were a majority of males with generalized late-onset MG occurring after the first dose of vaccine, similar to our patient. Only our patient showed a thymoma. Thymic mass and the positivity of AchR antibodies suggest that vaccination might have triggered a subclinical pre-existing MG with symptoms flaring. Clinicians should be aware of possible new-onset MG after COVID-19 vaccination, particularly in at-risk patients. Even though COVID-19 vaccination should be recommended in MG patients, particularly in well-compensated patients. However, more studies need to be performed in the future.

COVID-19 and Sepsis in an Atypical Case of Mixed Connective Tissue Disorder Presenting With a Myasthenic Crisis.

Myasthenia gravis (MG) is an autoimmune illness that causes neuromuscular junctions to be damaged by anti-acetylcholine receptor antibodies. It is a very rare condition that is more common among women. Fatigable fluctuating diplopia or ptosis is the characteristic early appearance of this condition. Dysphagia or dysphonia may be present in rare cases. This illness can affect any group of skeletal muscles, including those in the neck and upper limbs. It can also affect the muscles that help you breathe, which can lead to breathing failure. We present a case of a 20-year-old female diagnosed with mixed connective tissue disease presenting with acute respiratory failure as the initial presentation of MG. Clinicians have to have a high index of suspicion for myasthenia when patients arrive with fatigable muscle weakness. This will cut down on the amount of money spent on investigations and the risk of morbidity.

MYASTHENIA GRAVIS PRECIPITATED BY ASYMPTOMATIC COVID-19 INFECTION, VACCINE, OR BOTH? HOW GENETIC PREDISPOSITION AND IMMUNE RESPONSES PLAY A ROLE IN THE NEUROMUSCULAR JUNCTION

SESSION TITLE: Autoimmune Disorders: Both Primary and Secondary SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: SARS-CoV-2 has demonstrated an impact on the lungs, leads to hypercoagulable states, and has caused immune-mediated reactions. Myasthenia Gravis (MG) represents a neuromuscular junction autoimmune disorder, with only a few case reports associated with new-onset MG following COVID-19 vaccination. Very rarely, MG has been reported in coexistence with Primary Sjogren's Syndrome (PSS). Here we present a case of new-onset MG in a patient with a positive COVID-19 a nasopharyngeal RT-PCR swab test, who received 3 doses of the Moderna COVID-19 vaccine with the latest dose 2 weeks prior to presentation and demonstrated positive PSS antibodies (Abs). CASE PRESENTATION: A 67-year-old male with no known past medical history presented with complaints of progressive weakness for 2 weeks, which began as diffuse malaise, and progressed to upper and lower extremity weakness with associated neck weakness, and dysphagia. Physical exam was remarkable for bilateral ptosis and difficulty ambulating. The patient was admitted to the ICU for suspected new-onset neuromuscular junction disorder and for close monitoring of his respiratory function. COVID-19 PCR was positive. MG and autoimmune disease workup was sent along with COVID-19 antibody testing. Chest X-Ray, CT head, and CT thorax were unremarkable. The patient was started on Pyridostigmine and IVIG, with low dose prednisone initiated on day 3 of admission. On the fifth day, symptoms improved significantly. Antibodies (Ab) against Acetylcholine (Ach) receptors were elevated and the diagnosis of MG was made. PSS Abs were also detected. Lyme, HIV, RPR, thyroid, and B12 levels were within the normal range which may mimic NMJ dysfunction. DISCUSSION: MG represents an autoimmune disorder due to autoantibodies against nicotinic AChR at the neuromuscular junction;however, these Abs can also target non-AChR muscle-specific receptor tyrosine kinase (MUSK). The exact mechanism of the autoimmune response with MG is not fully understood;however, there have been associations found with thymus gland hyperplasia and neoplasm when anti-AChR Abs are involved. Genetic predisposition is also likely to play a role. Viral and bacterial infections are established triggers for a myasthenic crisis in patients with pre-existing MG;however, there is yet to be a clear consensus regarding infections causing MG in otherwise healthy patients. As our pt did receive the COVID-19 vaccine, we have to consider an autoimmune reaction secondary to his administration. CONCLUSIONS: COVID-19 vaccines have demonstrated autoimmune responses such as myocarditis and myasthenic crisis in individuals. There have also been documented cases of MG in symptomatic COVID-19 infections. Given these findings, this patient may have experienced an environmental insult on top of a genetic predisposition and may warrant further investigation in patients with similar presentations. Reference #1: Sriwastava S, Tandon M, Kataria S, Daimee M, Sultan S. New onset of ocular myasthenia gravis in a patient with COVID-19: a novel case report and literature review. J Neurol. 2021 Aug;268(8):2690-2696. doi: 10.1007/s00415-020-10263-1. Epub 2020 Oct 12. PMID: 33047223;PMCID: PMC7549728. Reference #2: Chavez A, Pougnier C. A Case of COVID-19 Vaccine Associated New Diagnosis Myasthenia Gravis. J Prim Care Community Health. 2021 Jan-Dec;12:21501327211051933. doi: 10.1177/21501327211051933. PMID: 34709075;PMCID: PMC8559213. Reference #3: Witberg G, Barda N, Hoss S, Richter I, Wiessman M, Aviv Y, Grinberg T, Auster O, Dagan N, Balicer RD, Kornowski R. Myocarditis after Covid-19 Vaccination in a Large Health Care Organization. N Engl J Med. 2021 Dec 2;385(23):2132-2139. doi: 10.1056/NEJMoa2110737. Epub 2021 Oct 6. PMID: 34614329;PMCID: PMC8531986. DISCLOSURES: No relevant relationships by Brooke Kania No relevant relationships by Anas Mahmoud No relevant relationships by Ahmed Salem No relevant elationships by Jessimar Sanchez No relevant relationships by Shivanck Upadhyay No relevant relationships by Deniz Yucel

Electrodiagnostic Findings in Covid patients: A single center experience

Objective: Our study objective is to evaluate the electromyography and nerve conduction study (EMG/NCS) findings among COVID-19 patients and look for possible correlations. Background: Neurological manifestations in patients with coronavirus disease 2019 (COVID-19) have been reported from early features of anosmia and dysgeusia to widespread involvement of the central nervous system, peripheral nervous system, as well as the neuromuscular junction and muscle. Design/Methods: This is a hospital-based retrospective observational study. All COVID-19 patients between the period of 1st January 2020 to 31st December 2020 undergoing an EMG/NCS were included. Results: Eighteen patients (12 male and 6 female) were included. The mean age was 55 ±12 years. 11 patients required intubation for a mean period of 18.6 days (range: 3-37 days). Electrodiagnostic findings were consistent with a myopathy in a majority of these patients (82%). Five of them also had a concurrent axonal neuropathy. In the remaining patients who did not require intubation (n=7), three patients had myopathic EMG changes and one had Guillain Barre syndrome. Conclusions: Myopathic EMG changes are commonly seen in critically ill COVID-19 patients, especially with a prolonged hospital stay. At this time, there are no neuromuscular-specific recommendations for patients who contract COVID-19. Only time and additional data will unveil the varying nature and potential neurological sequelae of COVID-19.

Retrospective Cohort Study Evaluating Outcomesin MyastheniaGravis Patients with COVID-19

Objective: We evaluated clinical outcomes of myasthenia gravis (MG) patients with COVID-19 infection to determine factors associated with poor outcomes. Background: MG is an autoimmune disease affecting the neuromuscular junction. MG patients often manifest dyspnea and dysphagia and have an increased risk of infection due to immunosuppressants use, which may compound the severity of COVID-19 symptoms. A comprehensive understanding of clinical outcomes of MG-COVID patients is crucial in clinical decision making. Design/Methods: We conducted a retrospective cohort study using the Optum® de-identified COVID-19 Electronic Health Record (EHR) data. Primary outcomes include death, hospitalization, intubation, and ICU stay. We analyzed factors that may affect the outcomes such as age, sex, ethnicity, geographic region, month of COVID-19 diagnosis, comorbidities, and MG-specific treatments. Then, we compared these outcomes with non-MG COVID as well as rheumatoid arthritis (RA), systemic lupus (SLE) and multiple sclerosis (MS) with COVID-19 using a modified multivariable Poisson regression model. Results: Our study includes total of 421,086 individuals with COVID-19 among which 377 were MG-COVID. MG was not associated with increased risk of ventilator use or death but was associated with increased risk of hospitalization (aRR=1.28, 95% CI 1.13-1.46, p <0.001) and ICU stay (aRR=1.51, 95% CI 1.16-1.96, p=0.002) when accounting for the covariates in COVID-19. The mortality of the MG-COVID subgroup was 10%, and it was associated with age 75 or older (aRR=9.57, 95% CI 1.56-58.76, p=0.015) and presence of dysphagia (aRR=1.84, 95% CI 1.06- 3.21, p=0.031) but not immunosuppressants use. The MG-COVID had higher adjusted risks of hospitalization and ICU admission compared to the RA-COVID but similar to the SLE- and MS-COVID subgroups. Conclusions: Our study provides insight into how COVID-19 infection affected MG patients. Neurologists may consider these outcomes when providing MG with COVID-19 patients and their families with treatment options, vaccination counseling, and prognosis.

Issue Information

This special issue includes 35 articles focusing on COVID-19 as an unforgettable challenge for the neurology community. Topics discussed are: dementia and cognitive disorders;stroke;movement disorders;infectious diseases;multiple sclerosis;muscled and MNJ disorders;headaches;neurocritical care;neuroimmunology;and neuropathies.

Myasthenia gravis exacerbation and myasthenic crisis associated with COVID-19: case series and literature review.

BACKGROUND: Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction that can be exacerbated by many viral infections, including COVID-19. The management of MG exacerbations is challenging in this scenario. We report 8 cases of MG exacerbation or myasthenic crisis associated with COVID-19 and discuss prognosis and treatment based on a literature review. RESULTS: Most patients were female (7/8), with an average age of 47.1 years. Treatment was immunoglobulin (IVIG) in 3 patients, plasma exchange (PLEX) in 2 patients, and adjustment of baseline drugs in 3. In-hospital mortality was 25% and 37.5% in 2-month follow-up. DISCUSSION: This is the largest case series of MG exacerbation or myasthenic crisis due to COVID-19 to this date. Mortality was considerably higher than in myasthenic crisis of other etiologies. Previous treatment for MG or acute exacerbation treatment did not seem to interfere with prognosis, although sample size was too small to draw definitive conclusions. Further studies are needed to understand the safety and effectiveness of interventions in this setting, particularly of PLEX, IVIG, rituximab, and tocilizumab.