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Guo M, Shang S, Li M, Cai G, Li P, Chen X, Li Q. Understanding autoimmune response after SARS-CoV-2 infection and the pathogenesis/mechanisms of long COVID. MEDICAL REVIEW (2021) 2024; 4:367-383. [PMID: 39444797 PMCID: PMC11495526 DOI: 10.1515/mr-2024-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/04/2024] [Indexed: 10/25/2024]
Abstract
COVID-19 posed a major challenge to the healthcare system and resources worldwide. The popularization of vaccines and the adoption of numerous prevention and control measures enabled the gradual end of the COVID-19 pandemic. However, successive occurrence of autoimmune diseases in patients with COVID-19 cannot be overlooked. Long COVID has been the major focus of research due to the long duration of different symptoms and the variety of systems involved. Autoimmunity may play a crucial role in the pathogenesis of long COVID. Here, we reviewed several autoimmune disorders occurring after COVID-19 infection and the pathogenesis of long COVID.
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Affiliation(s)
- Ming Guo
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases Research, Beijing 100853, China
| | - Shunlai Shang
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases Research, Beijing 100853, China
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Mengfei Li
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases Research, Beijing 100853, China
| | - Guangyan Cai
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases Research, Beijing 100853, China
| | - Ping Li
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases Research, Beijing 100853, China
| | - Xiangmei Chen
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases Research, Beijing 100853, China
- Haihe Laboratory of CellEcosystem, China
| | - Qinggang Li
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases Research, Beijing 100853, China
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Feiz H, Castellano C, Feiz L. Complications of Long COVID: Unraveling a Case of Very-Late-Onset Myasthenia Gravis. Cureus 2024; 16:e70552. [PMID: 39479090 PMCID: PMC11524643 DOI: 10.7759/cureus.70552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Accepted: 09/10/2024] [Indexed: 11/02/2024] Open
Abstract
Myasthenia gravis (MG) is defined as an autoimmune neuromuscular disorder where autoantibodies disrupt synaptic transmission at the neuromuscular junction by targeting the acetylcholine receptor (AChR), muscle-specific kinase (MuSK), or other proteins related to the AChR complex. This disruption leads to characteristic muscle weakness and rapid fatigability. Clinically, MG is classified based on the age of onset into three distinct categories: early-onset MG (younger than 50 years), late-onset MG (between 50 and 64 years), and very-late-onset MG (65 years and older). We present a rare case of an 81-year-old man who presented with dysarthria, shortness of breath, diplopia, and oropharyngeal dysphagia to both solids and liquids for approximately seven days and was noted to be more progressive in the last 48 hours prior to his presentation to the emergency room. Upon arrival at the emergency room, he complained of shortness of breath and diplopia. Of note, approximately four months prior to this admission, he was diagnosed with COVID-19 pneumonia and was treated appropriately with remdesivir and corticosteroids. He had an uneventful COVID-19 pneumonia hospitalization and was discharged home. Given the progressive nature of his symptomatology, particularly dyspnea, he was transferred to the ICU for further evaluation and treatment. Laboratory results were positive for AChR binding, blocking, and modulating antibodies, confirming the diagnosis of MG. The patient received treatment consisting of pyridostigmine, a pulse dose of methylprednisolone, and intravenous immunoglobulin (IVIG) therapy. This case is unique and highlights a case of a very late onset of MG and the manifestation of new-onset MG four months following COVID-19. Additionally, this patient had a very delayed onset of MG symptoms, as he presented four months after his infection with COVID-19, compared to the average onset of reported cases of post-COVID MG being four to eight weeks post-infection with COVID-19. This uniquely delayed onset, occurring beyond a three-month window post-COVID-19 infection, aligns with the criteria established by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) for a diagnosis of "Post-COVID Condition," also known as "Long COVID." This case illustrates the intricate link between post-viral states and autoimmune responses, particularly in geriatric patients. The pathophysiology linking COVID-19 to MG primarily involves immune dysregulation triggered by the viral infection, which may disrupt immune tolerance and lead to clinical autoimmunity. This case stresses the need for vigilance in diagnosis and managing neurological complications in the context of viral respiratory illnesses, particularly in vulnerable populations.
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Affiliation(s)
- Hamid Feiz
- Internal Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
| | - Courteney Castellano
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Leyla Feiz
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
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Akbari A, Hadizadeh A, Islampanah M, Salavati Nik E, Atkin SL, Sahebkar A. COVID-19, G protein-coupled receptor, and renin-angiotensin system autoantibodies: Systematic review and meta-analysis. Autoimmun Rev 2023; 22:103402. [PMID: 37490975 DOI: 10.1016/j.autrev.2023.103402] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/20/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION There are an increasing number of reports of autoantibodies (AAbs) against host proteins such as G-protein coupled receptors (GPCRs) and the renin-angiotensin system (RAS) in COVID-19 disease. Here we have undertaken a systematic review and meta-analysis of all reports of AAbs against GPCRs and RAS in COVID-19 patients including those with long-COVID or post-COVID symptoms. METHODS PubMed, Embase, Web of Science, and Scopus databases were searched to find papers on the role of GPCR and RAS AAbs in the presence and severity of COVID-19 or post- COVID symptoms available through March 21, 2023. Data on the prevalence of AngII or ACE, comparing AngII or ACE between COVID-19 and non-COVID-19, or comparing AngII or ACE between COVID-19 patients with different disease stages were pooled and a meta-analysed using random- or fixed-effects models were undertaken. RESULTS The search yielded a total of 1042 articles, of which 68 studies were included in this systematic review and nine in the meta-analysis. Among 18 studies that investigated GPCRs and COVID-19 severity, 18 distinct AAbs were detected. In addition, nine AAbs were found in case reports that assessed post- COVID, and 19 AAbs were found in other studies that assessed post- COVID or long- COVID symptoms. Meta-analysis revealed a significantly higher number of seropositive ACE2 AAbs in COVID-19 patients (odds ratio = 7.766 [2.056, 29.208], p = 0.002) and particularly in severe disease (odds ratio = 11.49 [1.04, 126.86], p = 0.046), whereas AngII-AAbs seropositivity was no different between COVID-19 and control subjects (odds ratio = 2.890 [0.546-15.283], p = 0.21). CONCLUSIONS GPCR and RAS AAbs may play an important role in COVID-19 severity, the development of disease progression, long-term symptoms COVID and post- COVID symptoms.
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Affiliation(s)
- Abolfazl Akbari
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alireza Hadizadeh
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Muhammad Islampanah
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ensie Salavati Nik
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Stephen L Atkin
- Royal College of Surgeons in Ireland, Bahrain, Adliya, PO Box 15503, Bahrain
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.; Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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Croitoru CG, Cuciureanu DI, Hodorog DN, Grosu C, Cianga P. Autoimmune myasthenia gravis and COVID-19. A case report-based review. J Int Med Res 2023; 51:3000605231191025. [PMID: 37565671 PMCID: PMC10422912 DOI: 10.1177/03000605231191025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/13/2023] [Indexed: 08/12/2023] Open
Abstract
A potential relationship between COVID-19 infection and new onset myasthenia gravis (MG) has been suggested by the coexistence of these two diseases in a number of reports. This study aimed to assess their relationship by reviewing case studies of COVID-19 followed by new onset MG published between 01 December 2019 and 30 June 2023 identified by a search of PubMed/Medline database. In addition, we reviewed evidence in favour and against a potential cause and effect association, and described possible mechanisms that would underpin such a relationship. We identified 14 publications that reported 18 cases. Analysis showed the following features: age 19-83 years; 10 men/8 women; median time interval between COVID-19 and MG (17, 5-56 days); autoimmune comorbidities (4); generalised MG (14); ocular MG (4); thymoma (3); antiacetylcholine receptor antibody (16); antimuscle-specific kinase antibodies (2). All patients improved following treatment. Proof of direct causality between the two conditions can only be established in time by confirming epidemiological increase in the incidence of MG or elucidating pathogenic mechanisms to substantiate a possible cause-effect association, or both.
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Affiliation(s)
- Cristina Georgiana Croitoru
- Department of Immunology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
- Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, Iași, Romania
| | - Dan Iulian Cuciureanu
- Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, Iași, Romania
- Department Medical III, Department of Neurology,” Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
| | - Diana Nicoleta Hodorog
- Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, Iași, Romania
- Department Medical III, Department of Neurology,” Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
| | - Cristina Grosu
- Department Medical III, Department of Neurology,” Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
| | - Petru Cianga
- Department of Immunology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
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Sadiq W, Waleed MS, Rizvi TA, Khan S, El Hage H. Myasthenia Gravis Associated With COVID-19 Infection. Cureus 2023; 15:e39506. [PMID: 37366447 PMCID: PMC10290576 DOI: 10.7759/cureus.39506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 06/28/2023] Open
Abstract
COVID-19 first emerged in Wuhan, China in late December 2019. The disease majorly involves the lungs leading to various respiratory complications; however, neurological manifestations of the disease are also described in the literature. Here, we report a case of COVID-19-induced seronegative myasthenia gravis (MG). We discuss the cases of COVID-19 and MG already described in the literature in regard to their presentation and serological findings to better understand the association between the two disease processes. MG may be missed in patients after COVID-19 infections because of the comorbidities and anti-acetylcholine receptor and anti-muscle-specific tyrosine kinase antibodies being negative. Evidence from more studies will help analyze the pathological timeline of the disease process and the immunological characteristics of COVID-19-induced MG which can prove to have morbidity and mortality benefit in patients with COVID-19-induced MG.
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Affiliation(s)
- Waleed Sadiq
- Pulmonary and Critical Care Medicine, Staten Island University Hospital, Staten Island, USA
| | | | - Taqi A Rizvi
- Internal Medicine, Staten Island University Hospital, Staten Island, USA
| | - Shahkar Khan
- Internal Medicine, Staten Island University Hospital, Staten Island, USA
| | - Halim El Hage
- Pulmonary and Critical Care Medicine, Staten Island University Hospital, Staten Island, USA
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Tereshko Y, Gigli GL, Pez S, De Pellegrin A, Valente M. New-onset Myasthenia Gravis after SARS-CoV-2 infection: case report and literature review. J Neurol 2023; 270:601-609. [PMID: 36352330 PMCID: PMC9645742 DOI: 10.1007/s00415-022-11472-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/22/2022] [Accepted: 11/01/2022] [Indexed: 11/10/2022]
Abstract
We report the case of a 19-year-old female patient who developed Myasthenia Gravis 13 days after SARS-CoV-2 infection with positive RT-PCR testing. Her symptoms initially involved the oculo-bulbar district, but they gradually worsened in 3 months converting into a generalized form of Myasthenia Gravis complicated with a myasthenic crisis. A high level of anti-acetylcholine receptor antibodies was found in the serum, while anti-MuSK antibodies were negative; Repetitive Nerve Stimulation and Single-fiber Electromyography were suggestive of Myasthenia Gravis. Intravenous immunoglobulin courses and specific therapy were able to improve her symptoms, but thymic resection was needed to control the disease. This is a report of new-onset Myasthenia Gravis correlated to COVID-19 in which thymic resection was described and the histologic analysis of the thymus was performed showing thymic hyperplasia despite negative thoracic Magnetic Resonance Imaging. SARS-CoV-2 infection releases inflammatory cytokines that could dysregulate the immune system and lead to Myasthenia Gravis in susceptible subjects.
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Affiliation(s)
- Yan Tereshko
- grid.411492.bClinical Neurology Unit, Department of Neuroscience, Udine University Hospital, Piazzale S. Maria Della Misericordia 15, 33100 Udine, Italy
| | - Gian Luigi Gigli
- grid.411492.bClinical Neurology Unit, Department of Neuroscience, Udine University Hospital, Piazzale S. Maria Della Misericordia 15, 33100 Udine, Italy ,grid.5390.f0000 0001 2113 062XDepartment of Medicine (DAME), University of Udine, Udine, Italy
| | - Sara Pez
- grid.411492.bClinical Neurology Unit, Department of Neuroscience, Udine University Hospital, Piazzale S. Maria Della Misericordia 15, 33100 Udine, Italy
| | - Alessandro De Pellegrin
- grid.411492.bDepartment of Pathology, Udine University Hospital, Piazzale S. maria della Misericordia 15, 33100 Udine, Italy
| | - Mariarosaria Valente
- grid.411492.bClinical Neurology Unit, Department of Neuroscience, Udine University Hospital, Piazzale S. Maria Della Misericordia 15, 33100 Udine, Italy ,grid.5390.f0000 0001 2113 062XDepartment of Medicine (DAME), University of Udine, Udine, Italy
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Muacevic A, Adler JR, Roy M. A Case Report and Literature Review of New-Onset Myasthenia Gravis After COVID-19 Infection. Cureus 2022; 14:e33048. [PMID: 36721575 PMCID: PMC9881688 DOI: 10.7759/cureus.33048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2022] [Indexed: 12/29/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disorder affecting the neuromuscular junction caused by a B-cell-mediated, T-cell-dependent immunologic attack at the end plate of the postsynaptic membrane. Attack on muscle acetylcholine receptors (AChR) of the postsynaptic membrane due to the AChR, muscle-specific tyrosine kinase, or lipoprotein receptor-related peptide 4 antibodies lead to symptoms of painless, fluctuating weakness of muscle groups and often begins with ocular signs and symptoms. Coronavirus disease 2019 (COVID-19) is an acute respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus closely related to SARS-CoV. Serious neurologic complications are infrequent and diverse with reported cases of stroke, encephalitis/meningitis, Guillain-Barré syndrome, acute disseminated encephalomyelitis, ataxia, and unspecified limb weakness. MG is a rarely reported sequela of COVID-19 infection. To date, there are 15 reported cases of post-COVID-19 MG. In this article, we present a case of post-COVID-19 MG and a concise review of other reported cases. An 83-year-old Caucasian male with a medical history of atrial fibrillation status post-ablation and non-ischemic cardiomyopathy was initially admitted for COVID-19 pneumonia. He was treated with remdesivir, convalescent plasma, and supplemental oxygen therapy but did not require invasive mechanical intubation. One month after discharge, he started experiencing fatigue with muscle weakness and progressive dyspnea. He progressed to develop dysphonia, especially at the end of the day. After extensive workup, he was diagnosed with MG with a positive antibody against the AChR. The chronological events of developing slowly worsening muscular weakness after recovering from COVID-19 infection and positive AChR antibody led to the diagnosis of post-COVID-19 new-onset MG. Post-COVID-19 fatigue, long-term use of steroids, and intensive care unit-related physical deconditioning can be confounders in the clinical presentation of post-COVID-19 new-onset MG. Careful history-taking and meticulous assessment of chronological events are needed to diagnose this rare entity.
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Dinkin M, Sathi S. Efferent neuro-ophthalmic complications of coronavirus disease 2019. Curr Opin Ophthalmol 2022; 33:471-484. [PMID: 36165417 DOI: 10.1097/icu.0000000000000904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW We set out to describe efferent neuro-ophthalmological complications that have been reported in association with coronavirus disease 2019 (COVID-19) infection. We describe syndromes affecting ocular motility and elaborate on mechanisms of disease, including para-infectious inflammation, hypercoagulability, endothelial damage, and direct neurotropic viral invasion. Despite global vaccination programs, COVID-19 continues to pose an international threat that may rarely result in diplopia or nystagmus. RECENT FINDINGS Efferent complications include cranial nerve palsies leading to diplopia, either isolated or in association with Miller Fisher syndrome. Nystagmus has been observed in the setting of hemorrhagic acute necrotizing encephalopathy and brainstem infarcts, and opsoclonus syndrome has been described. SUMMARY Observed neuro-ophthalmic associations need to be confirmed through larger comparative studies. Meanwhile, the range of possible complications should be recognized by neurologists and ophthalmologists alike, to facilitate faster diagnosis and treatment of both COVID-19 and its neuro-ophthalmic manifestations.
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Affiliation(s)
- Marc Dinkin
- Departments of Ophthalmology and Neurology, Weill Cornell Medical College
| | - Swetha Sathi
- M2, Weill Cornell Medical College, New York, New York, USA
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Croitoru CG, Cuciureanu DI, Prutianu I, Cianga P. Autoimmune myasthenia gravis after COVID-19 in a triple vaccinated patient. Arch Clin Cases 2022; 9:104-107. [PMID: 36176496 PMCID: PMC9512128 DOI: 10.22551/2022.36.0903.10212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Despite a well characterized mechanism, myasthenia gravis (MG) remains a dilemma in terms of etiology. Several case reports and series of cases suggest a potential cause-effect relation between SARS-CoV-2 infection or vaccination and MG. We present the case of an autoimmune MG occurring post Covid-19 in an elderly male, vaccinated with three doses of the BNT162b2/Pfizer-BioNTech vaccine. The 78-year-old male was admitted in the Neurology Clinic in early November 2021 with double vision, bilateral ptosis, dysphonia and dysphagia, 16 days after receiving a third dose of the BNT162b2/Pfizer-BioNTech SARS-CoV-2 vaccine and 12 days after testing positive for SARS-CoV-2 infection. The symptoms began to emerge at 9 days after COVID-19 diagnosis. Clinical neurological examination included ice-pack test and intramuscular neostigmine, both with positive results. Myasthenia gravis positive diagnosis was confirmed by slow repetitive nerve stimulation and abnormally increased serum levels of antibodies against acetylcholine receptors. Due to patient's refusal of further hospitalization, he was discharged with therapy recommendations. Under treatment with oral pyridostigmine, but no oral corticosteroid due to therapeutic noncompliance, the patient was readmitted two months later with aggravated symptoms. The myasthenic crisis was successfully treated with intravenous immunoglobulins, corticosteroid therapy and oral pyridostigmine. The novelty of the current case resides in the fact that, to the best of our knowledge, appears to be the first case of MG clinically manifested after COVID-19 infection in a fully vaccinated patient.
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Affiliation(s)
| | - Dan Iulian Cuciureanu
- I Neurology Clinic, Prof. Dr. Nicolae Oblu Emergency Clinical Hospital, Iaşi, Romania.,Department Medical III - Neurology, Grigore T. Popa University of Medicine and Pharmacy, Iaşi, Romania
| | - Iulian Prutianu
- Department Morpho-Functional Sciences I - Histology, Grigore T. Popa University of Medicine and Pharmacy, Iaşi, Romania
| | - Petru Cianga
- Department of Immunology, Grigore T. Popa University of Medicine and Pharmacy, Iaşi, Romania.,
Correspondence: Petru Cianga, Department of Immunology, Grigore T. Popa University of Medicine and Pharmacy, Iaşi, 16 Universitatii Str. Iasi 700115, Romania.
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