Myasthenia Gravis Exacerbation Following COVID-19 Vaccine: A Case Report
Keywords:Myasthenia Gravis , COVID-19 , Vaccine, Case Report
Background: Vaccination remains the mainstay of strategy for prevention of Coronavirus Disease-2019 (COVID-19). AZD1222 (AstraZeneca vaccine) was distributed in Sudan by the COVID-19 Vaccines Global Access facility in March 2021. It was added to the emergency use list by the WHO in mid-February 2021. However, vaccine safety among patients with autoimmune diseases, such as myasthenia gravis (MG), is yet to be established. MG is a relatively rare illness that could result in life-threatening complications. Myasthenic crisis is considered the most serious complication of MG that can lead to death due to aspiration and respiratory failure.
The case: We report the case of a 37-year-old Sudanese female who presented to the emergency room with an exacerbation of her normally well-controlled MG following her second dose of AZD1222 vaccination. She continued to deteriorate and was admitted to the intensive care unit, where she was intubated and placed on a mechanical ventilator. The low-income setting was a major barrier in obtaining intravenous immunoglobulin until the patient died. Our study aims to present an MG case with features of MG exacerbation following administration of a second dose of AZD1222.
Conclusion: Little is known about the effect of different COVID-19 vaccines on subgroups of patients with autoimmune diseases like MG. In our case, an exacerbation of MG may have been precipitated by the COVID-19 AstraZeneca vaccine. Therefore, more efforts and experimental studies may be needed, with closer vigilance in MG patients
World Health Organization. WHO Coronavirus (COVID-19) Dashboard. Available from: https://covid19.who.int/. Last updated January 28,2022; cited December 29,2021.
UNICEF. Sudan receives first delivery of COVID-19 vaccines with over 800,000 doses. Available from: https://www.unicef.org/press-releases/sudan-receives-first-delivery-covid-19-vaccines-over-800000-doses. Last updated March 3,2021; cited December 29,2021.
World Health Organization (WHO). Recommendation for an emergency use listing of AZD1222 submitted by AstraZeneca AB and manufactured by SK Bioscience Co Ltd. 2 (February 2020):1–23.
World Health Organization. WHO lists two additional COVID-19 vaccines for emergency use and COVAX roll-out. AstraZeneca/Oxford-developed vaccines to reach countries in the coming weeks. Available from: https://www.who.int/news/item/15-02-2021-who-lists-two-additional-covid-19-vaccines-for-emergency-use-and-covax-roll-out. Last updated February 15, 2021; cited December 29, 2021.
WHO. Summary of product characteristics. Available from: https://extranet.who.int/pqweb/sites/default/files/documents/WHO_SMPC_azd1222.pdf. Last updated No information; cited Mar 23, 2023.
Salari N, Fatahi B, Bartina Y, Kazeminia M, Fatahian R, Mohammadi P. Global prevalence of myasthenia gravis and the effectiveness of common drugs in its treatment: a systematic review and meta ‑ analysis. J Transl Med. 2021;7:1–23. DOI: https://doi.org/10.1186/s12967-021-03185-7
Thanvi BR, Lo TC. Update on myasthenia gravis. Postgrad Med J. 2004;80(950):690-700. DOI: https://doi.org/10.1136/pgmj.2004.018903
Schroeter M, Thayssen G, Kaiser J. Myasthenia gravis—exacerbation and crisis. Neurol Int Open. 2018;02:E10–5. DOI: https://doi.org/10.1055/s-0043-118441
Tagliaferri AR, Narvaneni S, Azzam MH, Grist W. A Case of COVID-19 Vaccine Causing a Myasthenia Gravis Crisis. Cureus. 2021;13(6):13–5. DOI: https://doi.org/10.7759/cureus.15581
Sonigra KJ, Sarna K, Vaghela VP, Guthua S. An Interesting Case of Fatal Myasthenic Crisis Probably Induced by the COVID-19 Vaccine. Cureus. 2022;14(3):e23251. DOI: https://doi.org/10.7759/cureus.23251
Ruan Z, Tang Y, Li C, Sun C, Zhu Y, Li Z, Chang T. COVID-19 Vaccination in Patients with Myasthenia Gravis: A Single-Center Case Series. Vaccines (Basel). 2021;9(10):1112. DOI: https://doi.org/10.3390/vaccines9101112
Patone M, Handunnetthi L, Saatci D, Pan J, Katikireddi SV, Razvi S, Hunt D, Mei XW, Dixon S, Zaccardi F, Khunti K, Watkinson P, Coupland CAC, Doidge J, Harrison DA, Ravanan R, Sheikh A, Robertson C, Hippisley-Cox J. Neurological complications after first dose of COVID-19 vaccines and SARS-CoV-2 infection. Nat Med. 2021;27(12):2144-2153. DOI: https://doi.org/10.1038/s41591-021-01556-7
Sansone G, Bonifati DM. Vaccines and myasthenia gravis: a comprehensive review and retrospective study of SARS-CoV-2 vaccination in a large cohort of myasthenic patients. J Neurol. 2022;269(8):3965-3981. DOI: https://doi.org/10.1007/s00415-022-11140-9
Moody R, Wilson K, Flanagan KL, Jaworowski A, Plebanski M. Adaptive Immunity and the Risk of Autoreactivity in COVID-19. Int J Mol Sci. 2021;22(16):8965. DOI: https://doi.org/10.3390/ijms22168965
Chavez A, Pougnier C. A Case of COVID-19 Vaccine Associated New Diagnosis Myasthenia Gravis. J Prim Care Community Health. 2021;12:21501327211051933. DOI: https://doi.org/10.1177/21501327211051933
Watad A, De Marco G, Mahajna H, Druyan A, Eltity M, Hijazi N, et al. Immune-mediated disease flares or new-onset disease in 27 subjects following mrna/dna sars-cov-2 vaccination. Vaccines. 2021;9(5):1–23. DOI: https://doi.org/10.3390/vaccines9050435
Evoli A. Myasthenia gravis: new developments in research and treatment. Curr Opin Neurol. 2017;30(5):464-470. DOI: https://doi.org/10.1097/WCO.0000000000000473
Mehta P, Mcauley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ, et al. Correspondence COVID-19 : consider cytokine storm syndromes and. Lancet. 2020;6736(20):19–20. DOI: https://doi.org/10.1016/S0140-6736(20)30628-0
Anand P, Slama MCC, Kaku M, Ong C, Cervantes-Arslanian AM, Zhou L, David WS, Guidon AC. COVID-19 in patients with myasthenia gravis. Muscle Nerve. 2020;62(2):254-258. DOI: https://doi.org/10.1002/mus.26918
Binks S, Vincent A, Palace J. Myasthenia gravis: a clinical-immunological update. J Neurol 2016;263(4):826-34. DOI: https://doi.org/10.1007/s00415-015-7963-5
Karimi N, Fatehi F, Okhovat AA, Abdi S, Sinaei F, Sikaroodi H, Vahabi Z, Nafissi S. Clinical features and outcomes of patients with myasthenia gravis affected by COVID-19: A single-center study. Clin Neurol Neurosurg. 2022;222:107441. DOI: https://doi.org/10.1016/j.clineuro.2022.107441
Camelo-Filho AE, Silva AMS, Estephan EP, Zambon AA, Mendonça RH, Souza PVS, Pinto WBVR, Oliveira ASB, Dangoni-Filho I, Pouza AFP, Valerio BCO, Zanoteli E. Myasthenia Gravis and COVID-19: Clinical Characteristics and Outcomes. Front Neurol. 2020;11:1053. DOI: https://doi.org/10.3389/fneur.2020.01053
International MG/COVID-19 Working Group, Jacob S, Muppidi S, Guidon A, Guptill J, Hehir M, et al. J Guidance for the management of myasthenia gravis (MG) and Lambert-Eaton myasthenic syndrome (LEMS) during the COVID-19 pandemic. J Neurol Sci. 2020;412:116803. DOI: https://doi.org/10.1016/j.jns.2020.116803
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