Myasthenic crisis due to anxiety and insomnia during COVID -19 pandemic.

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.