key: cord-0707988-w1kt7r00 authors: Saied, Zakaria; Rachdi, Amine; Thamlaoui, Saber; Nabli, Fatma; Jeridi, Cyrine; Baffoun, Nader; Kaddour, Chokri; Belal, Samir; Ben Sassi, Samia title: Myasthenia gravis and COVID‐19: A case series and comparison with literature date: 2021-04-29 journal: Acta Neurol Scand DOI: 10.1111/ane.13440 sha: fcd182e20487f8e6f8402a3d763fad63afe34a90 doc_id: 707988 cord_uid: w1kt7r00 OBJECTIVE: To describe presenting symptoms, clinical outcomes, and therapeutic management of concurrent Coronavirus disease 2019 (COVID‐19) infections in patients with a pre‐existing myasthenia gravis (MG). METHODS: We conducted a retrospective study in patients with preexisting MG presenting with concurrent COVID‐19 between September 21st and November 4th, 2020 when attending the emergency department or routine neurology consultation at the National Institute Mongi Ben Hamida of Neurology of Tunis, Tunisia. RESULTS: Five patients were identified. The Myasthenia Gravis Foundation of America scores (MGFA) prior to COVID‐19 infection were class I in one patient, class II (IIa, IIb) in two patients, and class IIIb in one patient. Four patients had mild to moderate courses of COVID‐19 infection. One patient presented a critical infection with acute respiratory disease syndrome (ARDS) requiring mechanical ventilation. Two of them also demonstrated signs of MG exacerbation requiring the use of intravenous immunoglobulin in one case. We maintained immunosuppressant therapy to MG in all our patients. All our patients received Azithromycin (AZM) as a part of specific drug treatment of COVID‐19 infection. Outcome was favorable in 4 patients and rapidly fatal evolution was observed in the patient with ADRS. DISCUSSIONS AND CONCLUSION: The results from our study suggest that prior MG activity could partially influence the subsequent clinical outcomes. It emerged also that ongoing long‐term immunosuppressive immunotherapy to MG should be maintained during the COVID‐19 pandemic and that AZM can be used safely in MG patients and concurrent COVID‐19 infection. This study was approved by our local ethics committee. Five patients (one male and four females) with pre-existing MG and concurrent COVID-19 infection were identified ( Table 1 ). The patients' median age was 54 years (age range: 37-60 years). The median duration of MG disease was 9 years (range: 3-15 years). Only one patient had obesity as comorbidity associated with MG. No discontinuation of baseline treatment was noted before the onset of COVID-19 symptoms. All our patients presented with suggestive symptoms of SARS-CoV-2 infection. Fever, headache, and myalgia were the most frequent complaints. They were observed in three patients. (Table 1 ). The median duration of symptoms prior to the consultation was 4 days (range: Patients 1, 2, 3, and 5 presented with mild to moderate COVID-19 infection. Patient 4 had a critical infection with acute respiratory disease syndrome (ARDS), requiring mechanical ventilation in an intensive care unit and he ultimately died. His prior MGFA severity class was IIIb (Table 1) . Chest X-ray did not show pulmonary infiltration for patients 1, 2, and 3. Chest CT scan of patient 4 showed large bilateral pulmonary opacities (supplementary data). Patient 5 had parenchymal pulmonary involvement estimated at 35% (supplementary Figure S1 ). In our series, concomitant signs of COVID-19 and MG exacerbation were observed in two patients ( Table 1 ). The favorable outcomes in our two patients support the hypothesis that COVID-19 infection has little impact on MG disease course as previously reported. 5 The median age in our series was 54 years which was comparable to the one reported in other MG series 2, 7 ( Table 2 ). In addition, it was observed that COVID-19 involved patients with a prolonged MG-disease course (Table 2 ). 2, 7 In an attempt to explain these findings, a possible pathophysiologic mechanism is the immunosenescence, an age-related alteration of the immune system, which is accompanied by an upregulation of On the other hand, the management of long-term immunomodulatory therapy of MG is also challenging. 7 Therapeutic approach varied, Huber et al. 5 stopped AZA in one patient and maintained baseline treatment for the three other patients of their series. In the series of Anand et al. 7 MMF was initially withheld in three patient, It is worth mentioning that despite this discontinuation, two out of these three patients needed respiratory support. In our own experience, long-term immunosuppressive ther- The immunopathology of MG involves the release of several cytokines by upregulated Th 17 cells resulting in a chronic inflammation of the neuromuscular junction. 19 Also, it was demonstrated elevated production of INF ȣ by memory T cell from a cohort of MG patients and Th 22 cells, secreting TNF ɑ are increased in MG. 19, 20 This is TA B L E 2 Comparison of our series to early reported series of Myasthenia Gravis patients with COVID-19 N Rein et al. 6 Camelo-Filho et al. 2 Huber et al. 5 Anand et al. 7 Our study pandemic have been advanced. The use of AZM, as a specific therapy for COVID-19 infection, was reassuring as shown in our study. No funding was received for this work. The authors report no conflict of interest. All authors have approved the final article. 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