key: cord-0894886-70dd4voc
authors: Galassi, Giuliana; Marchioni, Alessandro
title: Comment on case series of COVID-19 in patients with myasthenia gravis: a single institution experience by Županić et al.
date: 2021-10-04
journal: Acta Neurol Belg
DOI: 10.1007/s13760-021-01746-7
sha: 5a09731a4a5b40436dd863b596d87aec3a4e25be
doc_id: 894886
cord_uid: 70dd4voc

nan

therapy. The description of this case series is interesting and deserves a brief comment.

First, while for other neurological manifestations of central nervous system, it can be easy to establish a relation with COVID-19, in case of neuromuscular disorders, clinicians must be cautious in attributing the symptoms to worsening of the neurological status rather than to the COVID-19-itself [3, 4] . About 20% of patients with SARS-COV-2 exhibit respiratory weakness and failure, due to viral infection [5] . The development of selective respiratory muscles weakness could be a feature of COVID-19-related MG exacerbation, and may be triggered by increased inspiratory effort due to respiratory drive activation in the course of concurrent pneumonia [4] . In this scenario, early non-invasive pressure support could prevent fatigue and potentially avoid the need for MV in patients without significant alterations in gas exchange. Indeed, endotracheal intubation and MV, despite being the gold standard of treatment for acute respiratory failure due to MC, are associated with complications, including pneumonia and atelectasis, as well as prolonged ICU stays and difficult weaning [6] . Furthermore, some retrospective studies show that about 40% or more of MC patients undergoing MV fail weaning trial and require tracheostomy [6] .

Second, Županić et al. [1] do not provide details about severity of the concurrent pneumonia and radiological results; these data could clarify the interplay between MG and COVID-19 infection. Also, a functional respiratory muscle assessment might help to identify the development of weakness and the timing of initiation of non-invasive ventilation. However, given the fluctuating nature of muscle fatigue typical of MG, the respiratory functional assessment may also not be able to predict the need of ventilatory support.

Third, we think that the decisions on management of patients with generalized MG and SARS-CoV-2 infection should be taken thorough careful neurological surveillance. A cautious administration of IVIG is recommended in patients with concomitant SARS-CoV-2 infection, because widespread thrombosis has been reported in critically ill COVID-19 patients, as previous authors pointed out [1, 5, 7] . According to the literature, the IVIG treatment or plasma exchanges should be introduced in MG in case of clear-cut acute exacerbations of respiratory and neurological symptoms and in conditions defined as MC [6, 7] . The rational of the use of IVIG should be a short-term treatment in patients with life-threatening signs or when a rapid clinical response is needed or when other therapies are insufficiently effective [6, 7] . Finally, the Brazilian series [8] with 30% rate of death in MG hospitalized with COVID-19 describes patients with features falling into the definition of MC, as 87% were admitted to ICU and 73% needed MV.

The authors declare that they have no conflict of interest.

Ethical approval This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent Informed consent was obtained from all individual participants included in the study.

Case series of COVID-19 in patients with myasthenia gravis: a single institution experience

Myasthenia gravis: recommendations for clinical research standards. Task Force of the Medical Scientific Advisory Board of the Myasthenia Gravis Foundation of America

COVID-19 in patients with myasthenia gravis

Myasthenia gravis at the crossroad of COVID-19: focus on immunological and respiratory interplay

Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China

Myasthenic crisis demanding mechanical ventilation: a multicenter analysis of 250 cases

Myasthenic crisis in COVID-19

Myasthenia gravis and COVID-19: clinical characteristics and outcomes