Mycophenolate/prednisone

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

A 42-year-old woman developed coronavirus disease (COVID-2019) infection during treatment with mycophenolate and prednisone for myasthenia gravis.

The woman was diagnosed with acetylcholine receptor antibody-positive oculobulbar myasthenia gravis before nine months. She had presented initially with symptoms of double vision, drooping eyelids, difficulty swallowing with diurnal variation. Initially, she had failed her bedside swallow examination with notable aspiration to thin liquids on a modified barium swallow (MBS). She underwent plasmapheresis and had a complete recovery of symptoms. Earlier she had difficulty in swallowing even after IV immune-globulin. She was started on immunosuppressive treatment with gradually uptitrated prednisone 30mg daily and mycophenolate 1000mg twice daily [routes not stated] along with pyridostigmine for myasthenia gravis before discharge from the hospital. Her medical history included allergic rhinitis and generalised anxiety disorder. She had a recurrence of drooping eyelids with a change in voice, suggestive of myasthenia exacerbation, during her routine neurology clinic follow-up. She was started on regular plasma exchange with frequency of 3 exchanges every 4 weeks and continued taking mycophenolate and prednisone. Her chest CT revealed thymic carcinoma. Thymectomy was planned and was put on hold as per the patient's request. Four weeks ago, she presented to the emergency department (ED) with chills, fever, cough with minimal clear sputum production, decreased sense of taste and smell, decreased appetite, and exertional shortness of breath for 5 days. Two weeks before her presentation, she had traveled to a nearby city. Patchy infiltrates in the left lower lobe was noted from her chest X-ray suggestive of infection. Her laboratory investigation indicated elevated white blood cell count with lymphopenia. She was negative for Streptococcus pneumonia, urine Legionella and influenza A/B. She tested positive for COVID-19. A bedside negative inspiratory force (NIF) was 65cm H2O.

The woman was discharged from ED and was instructed to self-quarantine for the next 14 days, and to follow Center for Disease Control and Prevention guidelines for hand hygiene and contact precautions to prevent the spread of infection. She was also advised to return to the ED if her respiratory symptoms or myasthenia symptoms worsened. She continued her immuno-modulatory therapy including mycophenolate and steroids during this time (she had been on immuno-modulatory therapy for 7 months at that time). Her plasmapheresis was postponed to the post quarantine period on account of preventing the spread of infection to others. She recovered from COVID-19 infection without any complications. She did not develop any symptoms of myasthenia exacerbation during her course of infection and no changes were made to her immunosuppressive medications.