Dear Sir,
Myasthenic Crisis (MC) is a life-threatening presentation of Myasthenia Gravis (MG), and is precipitated by infection, aspiration, hot weather, stress, drugs, drug default and surgery [1,2]. The 2019 novel coronavirus (COVID 19) pandemic and lockdown has resulted in fear of infection and non-availability of drugs in patients with chronic diseases. We report a patient with MG whose MC was triggered by anxiety and insomnia during the COVID 19 pandemic.
A 54-year-old male presented with dyspnoea, ptosis, bulbar weakness and quadriparesis for five days without a known trigger of MC. He has been a known case of MG for 16 years, and was hospitalised several times due to MC (Table 1 ). He had thymectomy and was stable for two years with pyridostigmine, prednisolone and azathioprine. His single breath count was seven. Blood counts, serum chemistry, thyroid profile, electrocardiogram and chest radiograph were normal. He required non-invasive ventilation and prostigmine injection. On the 35th day of hospitalisation, he informed staff that he could not sleep “ever” since the corona epidemic began in India. His Hospital Anxiety and Depression Scale-A score was 12. He was counselled about COVID prevention, and prescribed alprazolam 0.125 mg at night followed by melatonin 3 mg. His sleep improved and paralleled with improvement in myasthenic weakness.
Table 1.
Clinical and treatment details during hospitalizations over 16 year follow up.
| SR No | Admission | Precipitating factor | MGFA Class | Type of Respiratory support | Plasmapheresis/IVIG | Duration of hospital stay(days) | Medications at discharge(Drugs with total daily mg dose) |
|---|---|---|---|---|---|---|---|
| 1. | May 2005 | Missed dose | IIIb | BIPAP | IVIG | 14 | Pyridostigmine (240) |
| Prostigmine (15) | |||||||
| Pyridostigmine (180) | |||||||
| Prednisolone (20) | |||||||
| 2. | June 2005 | Thymectomy & left pneumothorax | IIIb | BIPAP | 4 cycles of plasmapheresis | 39 | Pyridostigmine (240) |
| Prostigmine (15) | |||||||
| Pyridostigmine (180) | |||||||
| Prednisolone (20) | |||||||
| 3. | Nov 2007 | Lower respiratory tract infection | IIb | Oxygen | IVIG | 10 | Pyridostigmine (300) |
| Prostigmine (45) | |||||||
| Azathioprine (50) | |||||||
| Prednisolone (20) | |||||||
| Ramipril (2.5 mg) | |||||||
| Sulfamethoxazole trimethoprim (800 + 160) | |||||||
| 4. | March 2008 | Cholinergic crisis | IIb | Oxygen | None | 11 | Pyridostigmine (300) |
| Prostigmine (15) | |||||||
| Azathioprine (50) | |||||||
| Prednisolone (15) | |||||||
| Ramipril (2.5) | |||||||
| 5. | April 2008 | Lower respiratory tract infection | IIIb | BIPAP | IVIG | 11 | Pyridostigmine (300) |
| Prostigmine (15) | |||||||
| Azathioprine (50) | |||||||
| Prednisolone (15) | |||||||
| Ramipril (2.5) | |||||||
| 6. | Sep 2008 | Lower respiratory tract infection | IIIb | BIPAP | None | 7 | Pyridostigmine (214) |
| Prostigmine (15) | |||||||
| Azathioprine (50) | |||||||
| Prednisolone (10/5) alternate day | |||||||
| 7. | Aug 2010 | Lower respiratory tract infection | V | ventilator | plasmapheresis | 21 | Pyridostigmine (300) |
| Azathioprine (50) | |||||||
| Prednisolone (10) | |||||||
| 8. | Aug 2014 | Lower respiratory tract infection | IIIb | BIPAP | IVIG | 20 | Pyridostigmine (180) |
| Prostigmine (30) | |||||||
| Azathioprine (100) | |||||||
| Prednisolone (10) | |||||||
| 9. | Apr 2016 | Lower respiratory tract infection | V | Ventilator | IVIG | 32 | Pyridostigmine (180) |
| Azathioprine (100) | |||||||
| Prednisolone (20) | |||||||
| 10. | June 2018 | Hot weather Low back pain | IIb | Oxygen | None | 30 | Pyridostigmine (180) |
| Azathioprine (150) | |||||||
| Prednisolone (5) | |||||||
| Telmisartan (80) | |||||||
| Metformin (500) | |||||||
| 11. | Aug 2018 | Fluoroquinolone | IIIb | BIPAP | IVIG | 30 | Pyridostigmine (240) |
| Prostigmine (30) | |||||||
| Azathioprine (150) | |||||||
| Prednisolone (10) | |||||||
| Telmisartan (40) | |||||||
| Metformin (500) | |||||||
| 12. | Sep 2018 | Fluoroquinolone | IIIb | BIPAP | plasmapheresis | 20 | Pyridostigmine (240) |
| Prostigmine (45) | |||||||
| Azathioprine (150) | |||||||
| Prednisolone (10) | |||||||
| Telmisartan (40) | |||||||
| Metformin (1000) |
This patient highlights anxiety and insomnia as a trigger of MC. Emotional stress as a trigger of MC has been reported in one patient only who had concomitant Takotsubo myopathy [3]. Beta agonist increases cAMP at the neuromuscular junction leading to augmentation of acetylcholine quantal release and stabilization of acetylcholine receptors, but these effects may be offset by receptor desensitization at higher concentrations [4,5]. We have used small dose of alprazolam when he failed to respond to all the measures. Although sedation or anxiolytic is contraindicated in MC, these may be life-saving in appropriate settings. Therefore, attention to neuropsychiatric status is important in MG.
Ethical publication statement
This study was approved by the SGPGI Institute Ethics Committee. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guideline.
Patients consent for publication
Obtained.
Author’s contribution
JK: Conceptualisation, patients care and writing the manuscript. UKM: Patient care and writing manuscript. ND: Data collection.
Acknowledgement
We thank Mr. Shakti Kumar for secretarial help.
Footnotes
None of the authors has any conflict of interest to disclose.
The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: https://doi.org/10.1016/j.sleep.2020.08.008.
Conflict of interest
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References
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