Management of patients with generalised myasthenia gravis and COVID-19: four case reports

Myasthenia gravis (MG) is an autoimmune disease characterised by fluctuating muscle weakness with potentially life-threatening symptoms due to insufficiency of respiratory muscles. Treatment usually includes immunosuppressive drugs and cholinesterase inhibitors. COVID-19 is an infection caused by the newly discovered severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), defined as a pandemic by the World Health Organisation (WHO). Although guidelines for the management of patients with MG during the COVID-19 pandemic have been published,1 these recommendations are based on theoretical considerations only, as no clinical data are available. We describe four patients with generalised MG affected by COVID-19 (around 10% of patients in our cohort). Clinical data are summarised in table 1. View this table: Table 1 Clinical data of four patients with generalised gravis and SARS-CoV-2 ### Case 1 A 36-year-old female patient, class IIa according to the Myasthenia Gravis Foundation of America (MGFA) score (166 cm, 67 kg), presented to Geneva University Hospital on 15 March 2020 with myalgia, coughing and fever >38°C on the same day. She was taking azathioprine (AZA) 50 mg, reintroduced at the end of January 2020, and pyridostigmine 60 mg five to six times per day. The last deterioration of MG had occurred in January 2020 requiring intravenous immunoglobulin (IVIG) treatment (Myasthenia Muscle Score 65/100). COVID-19 real-time PCR (RT-PCR) revealed a positive result. Chest X-ray showed no pulmonary infiltration and peak flow was at 400 mL (82%). The Myasthenia Muscle …