ArticleFrontiers in immunology2025
COVID-19-associated delayed-onset MuSK-positive myasthenia gravis presenting solely with respiratory failure: a case report.
Article in Frontiers in immunology, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: Muscle-specific kinase (MuSK) myasthenia gravis is a rare autoimmune disorder of the neuromuscular junction that predominantly affects the bulbar and respiratory muscles. Although SARS-CoV-2 infection has been implicated as a precipitating factor, post-COVID-19 MuSK-MG remains exceedingly uncommon. Case presentation: A 29-year-old woman with a six-year history of unexplained exertional dyspnea was hospitalised twice for acute hypercapnic respiratory failure. The first episode, five months earlier, was attributed to severe tricuspid regurgitation; the second occurred eight weeks after mild COVID-19 and was characterized by coma due to hypercapnic respiratory failure without parenchymal lung disease. Diagnosis: Standard electrophysiology, neostigmine testing and acetylcholine-receptor antibodies (AChR-Ab) were negative. Given persistent ventilator dependence, MuSK antibodies (MuSK-Ab) were measured and found strongly positive. Interventions: The patient underwent five plasma-exchange sessions, then received oral prednisone (50 mg day), tacrolimus (1.5 mg q12h) and nebulized salbutamol. Outcomes: She was weaned from non-invasive ventilation by day 23, discharged on day 27 (mMRC grade I) and remained stable on low-dose prednisone/tacrolimus at three-month follow-up. Conclusion: SARS-CoV-2 infection may plausibly act as a trigger for late-onset MuSK-MG presenting as isolated hypercapnic respiratory failure. In otherwise unexplained weaning failure, neuromuscular-junction disease should be considered even without limb or ocular weakness. Early antibody testing and prompt immunomodulatory therapy [plasma exchange (PLEX) plus glucocorticoid/tacrolimus] may be life-saving and yield rapid recovery.
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