key: cord-0862768-ldhfppsm
authors: Kalita, Jayantee; Dongre, Nikhil; Misra, Usha K.
title: Myasthenic crisis due to anxiety and insomnia during COVID -19 pandemic
date: 2020-08-09
journal: Sleep Med
DOI: 10.1016/j.sleep.2020.08.008
sha: 9e6f32255f95003d7a39143c106285d6d03fcbc7
doc_id: 862768
cord_uid: ldhfppsm

nan

precipitated by infection, aspiration, hot weather, stress, drugs, drug default and surgery [1, 2] .

The 2019 novel coronavirus (COVID 19) pandemic and lockdown has resulted in fear of infection and non-availability of drugs in patients with chronic diseases. We report a patient with MG whose MC was triggered by anxiety and insomnia during the COVID 19 pandemic.

A 54-year-old male presented with dyspnoea, ptosis, bulbar weakness and quadriparesis for five days without a known trigger of MC. He has been a known case of MG for 16 years, and was hospitalised several times due to MC (Table 1) . He had thymectomy and was stable for two years with pyridostigmine, prednisolone and azathioprine. His single breath count was 7.

Blood counts, serum chemistry, thyroid profile, electrocardiogram and chest radiograph were normal. He required non-invasive ventilation and prostigmine injection. On the 35 th day of hospitalisation, he informed staff that he could not sleep "ever" since the corona epidemic began in India. His Hospital Anxiety and Depression Scale-A score was 12. He was counselled about COVID prevention, and prescribed alprazolam 0.125mg at night followed by melatonin 3mg. His sleep improved and paralleled with improvement in myasthenic weakness.

This patient highlights anxiety and insomnia as a trigger of MC. Emotional stress as a trigger of MC has been reported in one patient only who had concomitant Takotsubo myopathy [3] .

Beta agonist increases cAMP at the neuromuscular junction leading to augmentation of acetylcholine quantal release and stabilization of acetylcholine receptors, but these effects may be offset by receptor desensitization at higher concentrations [4, 5] . We have used small dose of alprazolam when he failed to respond to all the measures. Although sedation or J o u r n a l P r e -p r o o f 

Treatment of the Critically Ill Patient With Myasthenia Gravis. Neurological and Neurosurgical Intensive Care. 4 th ed

Predictors of outcome of myasthenic crisis

Emotional stress as a trigger of myasthenic crisis and concomitant takotsubo cardiomyopathy: a case report