Postinfectious Onset of Myasthenia Gravis in a COVID-19 Patient

Abstract

Objective: We report the case of a young woman with postinfectious onset of myasthenia gravis after COVID-19 with mild respiratory symptoms and anosmia/ageusia 1 month before admission to our neurological department. Methods: Patient data were derived from medical records of Hannover Medical School, Germany. Written informed consent was obtained from the patient. Results: The 21-year-old female patient presented with subacute, vertically shifted double vision evoked by right sided partial oculomotor paresis and ptosis. About 4 weeks earlier she had suffered from mild respiratory symptoms, aching limbs and head without fever, accompanied by anosmia/ageusia. During the persistence of the latter symptoms for around 10 days the patient had already noticed “tired eyes” and fluctuating double vision. Clinical assessment including a positive test with edrophonium chloride and increased acetylcholine receptor antibodies related the ocular manifestation etiologically to myasthenia gravis. Antibodies (IgA/IgG) against SARS-CoV-2 using three different serological tests (Abbott, DiaSorin, Euroimmun) were detected in serum suggesting this specific coronavirus as previously infectious agent in our patient. The myasthenic syndrome was treated successfully with intravenous immunoglobulins and oral pyridostigmine. Conclusion: This is the first case presentation of postinfectious myasthenia gravis as neurological complication in a COVID-19 patient.

Cerebrospinal fluid in COVID-19: A systematic review of the literature

“…CSF antibodies to SARS-CoV-2 were tested in 58/414 (14%) patients who did not have a positive CSF SARS-CoV-2 PCR (49/58 (84%) of whom had symptoms that localized to the CNS and 9/58 (16%) of whom had symptoms that localized to the PNS) [ 6 , 13 , 25 , 31 , 43 , 46 , 98 , 101 , 113 , 119 , 127 , 141 , 182 , 193 , 197 , 209 , 220 , 224 , 231 , 233 , 237 , 246 ]. Of these, 42/58 (72%) tested positive for SARS-CoV-2 antibodies in the CSF [ 6 , 25 , 31 , 43 , 46 , 98 , 119 , 127 , 193 , 197 , 209 , 224 , 231 , 237 ].…”

“…CSF oligoclonal bands were tested in 114 patients who did not have a positive CSF SARS-CoV-2 PCR or positive CSF antibodies to SARS-CoV-2 (103 (90%) who had symptoms that localized to the CNS and 11 (10%) who had symptoms that localized to the PNS) [ 9 , 10 , 19 , 20 , 35 , 36 , 42 , 44 , 45 , 58 , 69 , 74 , 79 , 81 , 101 , 112 , 113 , 116 , 117 , 126 , 127 , 130 , 135 , 136 , 147 , 149 , 152 , 154 , 160 , [168] , [169] , [170] , [171] , 177 , 181 , 182 , [185] , [186] , [187] , [188] , 191 , 194 , 203 , 205 , 207 , 209 , 212 , 213 , 215 , 216 , 218 , 233 , 242 , 245 ]. Of these, 35 (31%) had matched CSF and serum bands [ 9 , 35 , 79 , 112 , 113 , 127 , 147 , 170 , 171 , …”

“…There were 2/114 (2%) patients who did not have a positive CSF SARS-CoV-2 PCR or positive CSF antibodies to SARS-CoV-2 who had oligoclonal bands that were unique to the CSF, reflecting intrathecal antibody synthesis [ 101 , 171 ]. First, a 21-year-old woman who developed ptosis and diplopia a week after she had mild respiratory symptoms was found to have SARS-CoV-2 IgG and IgA antibodies in her serum (but not in her CSF) and positive oligoclonal bands type 2 (not matched in serum) in her CSF [ 101 ].…”

“…There were 2/114 (2%) patients who did not have a positive CSF SARS-CoV-2 PCR or positive CSF antibodies to SARS-CoV-2 who had oligoclonal bands that were unique to the CSF, reflecting intrathecal antibody synthesis [ 101 , 171 ]. First, a 21-year-old woman who developed ptosis and diplopia a week after she had mild respiratory symptoms was found to have SARS-CoV-2 IgG and IgA antibodies in her serum (but not in her CSF) and positive oligoclonal bands type 2 (not matched in serum) in her CSF [ 101 ]. Second, an 80-year-old patient who presented with hallucinations, memory problems and a seizure was found to have a positive nasopharyngeal SARS-CoV-2 PCR, CSF-specific oligoclonal bands and anti-contactin-associated protein 2 (Caspr2) IgG antibodies in serum and CSF [ 171 ].…”

Nicotinic cholinergic system and COVID-19: In silico evaluation of nicotinic acetylcholine receptor agonists as potential therapeutic interventions

“…They found that α7 nAChR activation increases STAT3 phosphorylation, decreases TNF-α and IL-6 expressions, and ultimately reduces viral myocarditis, indicating that α7 nAChR agonists could be a promising new strategy for patients with viral myocarditis. Also, a recent case study documented the post-infectious onset of myasthenia gravis in a COVID-19 patient, indicating that the SARS-CoV-2 virus could be an etiological agent in this case [ 61 ]. It is well-established that myasthenia gravis is associated with the presence of AChR antibodies, although it is unclear how this could be linked to the interactions presented herein.…”