Acute viral infection as a trigger for DSNMG: a case report

Abstract

Introduction. Categorical evidence shows that patients with Acute Respiratory Viral Infections have a higher risk of concurrently developing autoimmune diseases, reflecting phenotypic heterogeneity in MG. The association between Double Seronegative Myasthenia Gravis and Interstitial Pneumonia has been rarely reported in the Republic of Moldova. The present case aims to report the coexistence of dSNMG and ARVI confirmed in patient. Case presentation. Patient F, 58 years old, presented symptoms of ARVI, including sore throat, general weakness, headache for 10 days. On the 10th day, she developed general weakness, numbness throughout the body, with emphasis on the left hand, speech disturbances and diplopia. She sought medical attention at the Neuroemergency department for investigation. On clinical examination, the patient scored GCS=15p., bilateral external ophthalmoplegia, hemihypoesthesia on the L, Romberg sign(+), palatal veil deviated to the L, dysphagia, dysphonia, dysarthria, without signs of oral automatism. CSF analysis showed the Pandi test(+). Presumptive diagnosis: Myasthenic crisis. Within 2 days, the patient's condition worsened, adding respiratory disorders and sialorrhea, and transferred to the ICU. Initiation of treatment with Prednisolone 5mg with a daily dose increase up to 11 tab. and Calimin 60 mg tab.—initially ½ twice a day, then 1 tab. twice a day—was decided. Chest CT showed bilateral interstitial pneumonia, involuted thymus, and ground-glass opacities in S3-S5 on the R and S4-S5 on the L. The Prozerin test led to a slight regression of eyelid ptosis. On the 4th day of hospitalization, she was intubated and connected to assisted ventilation, with variable oxygen levels. On the 5th day from onset, antibodies were collected, and the result was: Anti-AChR antibodies (<0.07), Anti-MuSK antibodies (<0.01). On the 6th day, plasmapheresis was initiated, followed by immunoglobulin treatment with positive reaction, to which the patient responded positively. She was extubated after 13 days, transitioning to an oxygen mask with FiO2 ~30%. Discussions. This report describes the case of a woman who initially presented ARVI signs, and eventually diagnosed with dSNMG for both AChR and MuSK antibodies. The disease evolved negatively which caused the transfer to ICU. This case suggests that acute viral infections should be qualified as a trigger for agressive dSNMG. Conclusion. The case highlights the complexity of the relationship between ARVI and MG, emphasizing the importance of careful monitoring and management. These observations align with reports of other infections inducing autoimmune disorders, as well as the growing evidence of other neurological conditions with presumed autoimmune mechanisms following the onset of ARVI. have a higher risk of concurrently developing autoimmune d iseases, reflecting phenotypic heterogeneity in MG. The association between Double Seron egative Myasthenia Gravis and Interstitial Pneumonia has been rarely reported in the Republic of Moldova. The present case aims to report the coexistence of dSNMG and ARVI confirmed in patient. Case presentation. Patient F, 58 years old, presented symptoms of ARVI, inc luding sore throat, general weakness, headache for 10 days. On the 10th day, she de veloped general weakness, numbness throughout the body, with emphasis on the left han d, speech disturbances and diplopia. She sought medical attention at the Neuroemergency departme nt for investigation. On clinical examination, the patient scored GCS=15p., bilateral externa l ophthalmoplegia, hemihypoesthesia on the L, Romberg sign(+), palatal veil deviated to the L, dysphagia, dysphonia, dysarthria, without signs of oral automatism. CSF analysis showed the Pandi t est(+). Presumptive diagnosis: Myasthenic crisis. Within 2 days, the patient's condition worsened, adding respiratory disorders and sialorrhea, and transferred to the ICU. Initiation of treatment with Prednisolone 5mg with a daily dose increase up to 11 tab. and Calimin 60 mg tab.—initiall y ½ twice a day, then 1 tab. twice a day—was decided. Chest CT showed bilateral interstitial pneumonia, involuted thymus, and ground-glass opacities in S3-S5 on the R and S4-S5 on the L. The Prozerin test led to a slight regression of eyelid ptosis. On the 4th day of hospitalizatio n, she was intubated and connected to assisted ventilation, with variable oxygen levels. On t he 5th day from onset, antibodies were collected, and the result was: Anti-AChR antibodies (<0.07), Anti-MuSK antibodies (<0.01). On the 6th day, plasmapheresis was initiated, followed by immuno globulin treatment with positive reaction, to which the patient responded positively. She was extubated after 13 days, transitioning to an oxygen mask with FiO2 ~30%. Discussions. This report describes the case of a woman who initially pre sented ARVI signs, and eventually diagnosed with dSNMG for both AChR and MuSK antibo dies. The disease evolved negatively which caused the transfer to ICU. This case suggests that acute viral infections should be qualified as a trigger for agressive dSNMG. Conclusion. The case highlights the complexity of the relationship betwe en ARVI and MG, emphasizing the importance of careful monitoring and mana gement. These observations align with reports of other infections inducing autoimmune disorders, as we ll as the growing evidence of other neurological conditions with presumed autoimmune me chanisms following the onset of ARVI.