Autoimmune myasthenia gravis after COVID-19 in a triple vaccinated patient

Cristina-Georgiana Croitoru, Dan Iulian Cuciureanu, Iulian Prutianu, Petru Cianga


Despite a well characterized mechanism, Myasthenia gravis (MG) remains a dilemma in terms of etiology. Several case reports and series of cases suggest a potential cause-effect relation between SARS-CoV-2 infection or vaccination and MG. We present the case of an autoimmune MG occurring post Covid-19 in an elderly male, vaccinated with three doses of the BNT162b2/Pfizer-BioNTech vaccine. The 78-year-old male was admitted in the Neurology Clinic in early November 2021 with double vision, bilateral ptosis, dysphonia and dysphagia, 16 days after receiving a third dose of the BNT162b2/Pfizer-BioNTech SARS-CoV-2 vaccine and 12 days after testing positive for SARS-CoV-2 infection. The symptoms began to emerge at 9 days after COVID-19 diagnosis. Clinical neurological examination included ice-pack test and intramuscular neostigmine, both with positive results. Myasthenia gravis positive diagnosis was confirmed by slow repetitive nerve stimulation and abnormally increased serum levels of antibodies against acetylcholine receptors. Due to patient’s refusal of further hospitalization, he was discharged with therapy recommendations. Under treatment with oral pyridostigmine, but no oral corticosteroid due to therapeutic noncompliance, the patient was readmitted two months later with aggravated symptoms. The myasthenic crisis was successfully treated with intravenous immunoglobulins, corticosteroid therapy and oral pyridostigmine. The novelty of the current case resides in the fact that, to the best of our knowledge, appears to be the first case of MG clinically manifested after COVID-19 infection in a fully vaccinated patient.


post-infectious autoimmune myasthenia gravis; COVID-19; SARS-CoV-2 vaccination; cause-effect relationship

Full Text:



Bchtenia M, Girard C, Duchaine C, Laprise C. The outbreak of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): A review of the current global status. J Infect Public Health. 2020; 13(11):1601-1610. doi: 10.1016/j.jiph.2020.07.011

Guidon AC, Amato AA. COVID-19 and neuromuscular disorders. Neurology. 2020; 94(22):959-969. doi: 10.1212/WNL.0000000000009566

Gutierrez-Ortiz C, Mendez-Guerrero A, Rodrigo-Rey S, et al. Miller-Fischer Syndrome and polyneuritis cranialis in COVID-19. Neurology. 2020; 95:e601-605. doi:10.1212/WNL.0000000000009619

Taheri A, Davoodi L, Soleymani E, Ahmadi N. New-onset myasthenia gravis after novel coronavirus 2019 infection. Respirol Case Rep. 2022; 10(6):e0978. doi: 10.1002/rcr2.978

Ghafouri-Fard S, Azimi T, Hussen BM, Taheri M, Jalili Khoshnoud R. A Review on the Role of Non-Coding RNAs in the Pathogenesis of Myasthenia Gravis. Int J Mol Sci. 2021; 22(23):12964. doi: 10.3390/ijms222312964

Kawasaki T, Kawai T. Toll-like receptor signaling pathways. Front Immunol. 2014; 5:461. doi: 10.3389/fimmu.2014.00461

Cusick MF, Libbey JE, Fujinami RS. Molecular mimicry as a mechanism of autoimmune disease. Clin Rev Allergy Immunol. 2012; 42(1):102-111. doi:10.1007/s12016-011-8294-7

Cavalcante P, Cufi P, Mantegazza R, Berrih-Aknin S, Bernasconi P, Le Panse R. Etiology of myasthenia gravis: innate immunity signature in pathological thymus. Autoimmun Rev. 2013; 12(9):863-74. doi: 10.1016/j.autrev.2013.03.010

Jaretzki A 3rd, Barohn RJ, Ernstoff RM, et al. Mysthenia gravis: recomendations for clinical research standards. Task Force of the Medical Scientific Advisory Board of the Myasthenia Gravis Foundation of America. Neurology. 2000; 55(1):16-23. doi: 10.1212/wnl.55.1.16

Watad A, De Marco G, Mahajna H, et al. Immune-Mediated Disease Flares or New-Onset Disease in 27 Subjects following mRNA/DNA SARS-CoV-2 Vaccination. Vaccines (BAsel). 2021; 9(5):435. doi: 10.3390/vaccines9050435

Chavez A, Pougnier C. A Case of COVID-19 Vaccine Associated New Diagnosis Myasthenia Gravis. J Prim Care Community Health. 2021; 12:21501327211051933. doi: 10.1177/21501327211051933

Lee MA, Lee C, Park JH, Lee JH. Early-Onset Myasthenia Gravis Following COVID-19 Vaccination. J Korean Med Sci. 2022; 37(10):e50. doi: 10.3346/jkms.2022.37.e50

Pérez Álvarez ÁI, Suárez Cuervo C, Fernández Menéndez S. SARS-CoV-2 infection associated with diplopia and anti-acetylcholine receptor antibodies. Neurologia (Engl Ed). 2020; 35(4):264-65. doi: 10.1016/j.nrl.2020.04.003

Restivo DA, Centonze D, Alesina A, Marchese-Ragona R. Myasthenia Gravis Associated With SARS-CoV-2 Infection. Ann Intern Med. 2020; 173(12):1027-28. doi:10.7326/L20-0845

Huber M, Rogozinski S, Puppe W, et al. Postinfectious Onset of Myasthenia Gravis in a COVID-19 Patient. Front Neurol. 2020 11:576153. doi: 10.3389/fneur.2020.576153

Sriwastava S, Tandon M, Kataria S, Daimee M, Sultan S. New onset of ocular myasthenia gravis in a patient with COVID-19: a novel case report and literature review. J Neurol. 2021; 268(8):2690-96. doi: 10.1007/s00415-020-10263-1

Muhammed L, Baheerathan A, Cao M, Leite MI, Viegas S. MuSK Antibody-Associated Myasthenia Gravis With SARS-CoV-2 Infection: A Case Report. Ann Intern Med. 2021; 174(6):872-73. doi: 10.7326/L20-1298

Bhandarwar A, Jadhav S, Tandur A, Dhimole N, Wagh A, Bhondve S. Management of thymomatous myasthenia gravis - Case report of a rare Covid19 infection sequelae. Int J Surg Case Rep. 2021; 81:105771. doi: 10.1016/j.ijscr.2021.105771

Muralidhar Reddy Y, Osman S, Murthy JMK. Temporal association between SARS-CoV-2 infection and new-onset myasthenia gravis: is it causal or coincidental? BMJ Case Rep. 2021; 14(7):e244146. doi: 10.1136/bcr-2021-244146

Karimi N, Okhovat AA, Ziaadini B, Haghi Ashtiani B, Nafissi S, Fatehi F. Myasthenia gravis associated with novel coronavirus 2019 infection: A report of three cases. Clin Neurol Neurosurg. 2021; 208:106834. doi: 10.1016/j.clineuro.2021.106834

Assini A, Gandoglia I, Damato V, Rikani K, Evoli A, Del Sette M. Myasthenia gravis associated with anti-MuSK antibodies developed after SARS-CoV-2 infection. Eur J Neurol. 2021; 28(10):3537-39. doi: 10.1111/ene.14721

Galassi G. Marchioni A. Myasthenia gravis at the crossroad of COVID-19: focus on immunological and respiratory interplay. Acta Neurol Belg. 2021; 121(3):633-642. doi: 10.1007/s13760-021-01612-6


Copyright (c) 2022 Cristina-Georgiana Croitoru, Dan Iulian Cuciureanu, Iulian Prutianu, Petru Cianga

Creative Commons License
Archive of Clinical Cases is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.


ISSN: 2360-6975