For patients who are unaccustomed to life in the hospital, things can seem quite chaotic. From their beds, patients observe doctors running around, blood being taken at odd hours, and a revolving door of nurses, pharmacists, and staff. It is hence understandable that patients generally wish to be discharged as soon as possible.
However, all healthcare workers will know that there is indeed a method to the madness. In fact, a doctor’s daily life in the hospital is rather predictable (except in cases of emergencies). A doctor usually starts and ends his days with ward rounds, often with clinics and teaching sessions sandwiched in between. Drugs are prescribed strictly according to protocol, and the vital signs of all patients are constantly being monitored.
The COVID-19 pandemic did not just turn the commercial world into disarray, it was also an unwelcome interruption to how things were used to being done in clinical settings. In the UK, the National Health Service (NHS) was forced to postpone nonurgent surgeries to make way for the surge of COVID-19 patients, as was also done in US hospitals. Even the medical clothing most associated with the pandemic—personal protective equipment (PPE)—is hot, stuffy, and inconvenient. Entire wards became off-limits because they hosted COVID-19 patients.
In other words, an asteroid struck our delicately fine-tuned healthcare systems, and all stakeholders had to learn to adjust, and quickly. Immediately, concern was raised for patients who were not sick enough to be hospitalized but required constant medical surveillance, such as patients with myasthenia gravis. All of a sudden, a visit to a clinical facility was akin to a visit to a war zone—highly risky.
Anand and colleagues wrote in Muscle & Nerve, “Infections are a common trigger for myasthenic exacerbations. In the setting of COVID-19, hypoxemic respiratory failure secondary to the virus itself is common, but the course of the illness may also be complicated by myasthenic exacerbation and resultant neuromuscular respiratory failure.”
Read more about myasthenia gravis etiology
Many medical professionals had to turn to technology to reach their patients. As described in Neurological Sciences, Ricciardi and colleagues experimented with the use of telemedicine to ensure continuity of care for patients with myasthenia gravis. Their conclusion? “Telemedicine can offer valid support in (a) detecting early symptoms and signs of disease worsening, (b) preventing life-threatening complications, and (c) highlighting early changes in the clinical picture that require to be evaluated in a hospital setting.”
Myasthenia Gravis Occurring With COVID-19
Karimi and colleagues in Clinical Neurology and Neurosurgery presented 3 cases in which myasthenia gravis and COVID-19 came together. We will examine one of them closely.
A 57-year-old man was referred for ptosis, diplopia, dysphagia, and muscle fatigue over the last week. Prior to his developing ptosis and fatigue, he experienced a dry cough and a fever as high as 101.3 °F (38.5 °C) for 6 days. His past medical history included chronic heart failure, for which he received an implantable cardioverter-defibrillator.
A chest computed tomography (CT) scan revealed signs of pneumonia in the lower lobe of the lung. A reverse transcription-polymerase chain reaction (RT-PCR) assay on a nasal-pharyngeal swab returned positive for COVID-19.
Read more about myasthenia gravis treatment
The patient developed proximal weakness of the upper limbs, diplopia, and dysphagia with solid foods, consistent with myasthenia gravis foundation American (MGFA) class IIb. In addition, the patient demonstrated mild left ptosis, mild bilateral facial weakness, and mild proximal upper limb weakness.
Slow repetitive nerve stimulation at 3-hertz of the facial, median, ulnar, and radial nerves demonstrated a 10% to 40% decrease in response. His serum acetylcholine receptor antibody levels were raised to 8 pmol/L. Another chest CT scan revealed a normal thymus.
Pyridostigmine 60 mg 3 times a day and prednisone 25 mg daily were prescribed, and dysphagia and muscle weakness improved after 7 days, the authors wrote.
Separating the Cause and Effect
In this case study and the other 2 reported, the main issue was the difficulty in finding the cause-and-effect relationship between manifestations of myasthenia gravis and COVID-19 infection.
One example of this difficulty in establishing cause-and-effect is the symptom of muscle fatigue, which can plausibly be due to severe COVID-19 infection. In this case study, the patient began to develop myasthenia gravis shortly after contracting COVID-19. Does this indicate there is a link between myasthenia gravis and COVID-19 deserving of further research?
“In general, there are two potential explanations for our patients. First, the SARS-CoV-2, like other viruses, can play a role in activating latent autoimmune diseases such as MG,” Karimi et al wrote. “Second, the antigenic similarity and interaction between the SARS-CoV-2 epitope and the nicotinic acetylcholine receptor at the neuromuscular junction termed molecular mimicry could be responsible for MG induction.”
As the world of health care slowly resumes to normal during the endemicity of COVID-19, undoubtedly more research will shed light on the impact of this virus on myasthenia gravis and other diseases.
Ricciardi D, Casagrande S, Iodice F, et al. Myasthenia gravis and telemedicine: a lesson from COVID-19 pandemic. Neurol Sci. 2021;42(12):4889-4892. doi:10.1007/s10072-021-05566-8
Anand P, Slama MCC, Kaku M, et al. COVID-19 in patients with myasthenia gravis. Muscle Nerve. 2020;62(2):254-258. doi:10.1002/mus.26918
Karimi N, Okhovat AA, Ziaadini B, Haghi Ashtiani B, Nafissi S, Fatehi F. Myasthenia gravis associated with novel coronavirus 2019 infection: a report of three cases. Clin Neurol Neurosurg. 2021;208:106834. doi:10.1016/j.clineuro.2021.106834