MYASTHENIA GRAVIS CRISIS TRIGGERED BY COVID-19

Abstract

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: It is known that viral infections increase the risk of a crisis in patients with known myasthenia gravis (1) While COVID-19 has been associated with an array of neurologic complications including encephalopathy, strokes, and seizures (2), there have been no published reports of new or exacerbated neuromuscular conditions as a result of said infection We present a case of myasthenia gravis crisis precipitated by COVID-19 infection CASE PRESENTATION: 79 year old female patient with a past medical history of myasthenia gravis, mixed connective tissue disease-associated ILD on home oxygen, heart failure with a reduced ejection fraction, and a history of VTE on Apixaban who presented with dry cough, nausea, and diarrhea She was found to have worsening of her chronic hypoxic respiratory failure on admission, requiring high flow nasal cannula She tested positive for COVID-19 Her admission ABG showed a Pa O2 77 mmHg without hypercapnia Inflammatory markers were elevated;CRP 65 mg/L, LDH 500 IU/L, and d-dimer 3 99 ug/mL Other admission labs were notable for lactate 5 2 mmol/L, BNP 258 pg/mL Patient initially improved, but then started exhibiting increasing weakness which similar to her prior myasthenic crises Her neurological exam became notable for decreased motor strength in neck flexion and extension, diffuse weakness of proximal muscles (3/5 strength in proximal upper extremities, 4+/5 in distal upper extremities, 2/5 in proximal lower extremities, 4/5 in distal lower extremities), with decreased but symmetrical DTRs Her respiratory status declined, requiring a combination of high flow nasal cannula and non-rebreather mask to maintain adequate oxygenation Negative inspiratory force measurements were found to be decreased (NIF 20 from normal on admission) She was diagnosed with a myasthenic crisis She received IVIG without significant improvement and was then transferred to the medical ICU for further management In the ICU, patient treated with plasmapheresis and initial supported with NIPPV therapy with Bi-level PAP She unfortunately continued to decline and required intubation for further management Patient's course was then complicated by an acute stroke and her family elected to pursue comfort care She passed thereafter DISCUSSION: While the primary signs and symptoms of COVID-19 are fever, cough, and dyspnea, several neurological manifestations of the disease that have been reported In our case, this SARS COV-2 virus was the precipitating cause of this patient’s myasthenic crisis We wonder if experimental therapy with Remdisivir, Convalescent plasma or other immunologic agents could have prevented or shortened the duration of the myasthenic crisis in this patient CONCLUSIONS: Myasthenia gravis crises can be associated with COVID-19 Prompt detection & diagnosis can help improve outcomes Reference #1: Gilhus NE, Romi F, Hong Y, Skeie GO Myasthenia gravis and infectious disease J Neurol 2018;265(6):1251-1258 doi:10 1007/s00415-018-8751-9 Reference #2: Haddad S, Tayyar R, Risch L, et al Encephalopathy and seizure activity in a COVID-19 well controlled HIV patient [published online ahead of print, 2020 May 16] IDCases 2020;21:e00814 doi:10 1016/j idcr 2020 e00814 DISCLOSURES: no disclosure on file for Christopher Damiano;No relevant relationships by Elie Fares, source=Web Response no disclosure on file for Catherine Kuntz;No relevant relationships by Kriti Pathak, source=Web Response No relevant relationships by Ralph Tayyar, source=Web Response