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 Table of Contents    
Year : 2023  |  Volume : 16  |  Issue : 1  |  Page : 187-188  

New-onset ocular myasthenia gravis following SARS-CoV-2 infection

1 Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Aditya Birla Sankara Nethralaya, Kolkata, West Bengal, India
2 Department of Neurology, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India

Date of Submission27-Jan-2022
Date of Decision19-May-2022
Date of Acceptance09-Aug-2022
Date of Web Publication26-Dec-2022

Correspondence Address:
Prabrisha Banerjee
Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Aditya Birla Sankara Nethralaya, Kolkata, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ojo.ojo_33_22

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Keywords: COVID-19, cytokine dysregulation, myasthenia gravis, ocular myasthenia gravis, SARS-CoV-2

How to cite this article:
Banerjee P, Hassan H, Alam MS. New-onset ocular myasthenia gravis following SARS-CoV-2 infection. Oman J Ophthalmol 2023;16:187-8

How to cite this URL:
Banerjee P, Hassan H, Alam MS. New-onset ocular myasthenia gravis following SARS-CoV-2 infection. Oman J Ophthalmol [serial online] 2023 [cited 2023 Mar 26];16:187-8. Available from: https://www.ojoonline.org/text.asp?2023/16/1/187/365463

The novel coronavirus SARS-CoV-2 primarily affects the respiratory system and can produce severe acute respiratory syndrome. Case studies of the affected individuals have revealed an array of manifestations of the SARS-CoV-2 virus, including cardiovascular disease, acute renal injury, neurological disorder, coagulopathy, and elevated inflammatory markers.[1] Myasthenia gravis (MG) is an autoimmune disease, in which antibodies are directed against the acetylcholine receptors (Ach-Rs) at the postsynaptic neuromuscular junction. Viral infections have already been found to be a predisposing factor for MG. The emergence of SARS-CoV-2 has not only witnessed an exacerbation of previously diagnosed and stable cases of MG but also new-onset MG. We herewith report the third case of isolated new onset OMG following SARS-CoV-2 infection.[2] A 47-year-old Indian male presented to our clinic with complaints of drooping of both eyelids (left > right), with diurnal variation and occasional binocular double vision for the past 10 days. He gave a history of acquiring SARS-CoV-2 infection 1 month back. The infection was mild, and he recovered fully after 3 weeks of home isolation. His serum C-Reactive protein marker was raised. On examination, his best-corrected visual acuity was 20/20, N6 in both the eyes. Both eyes had variable ptosis with the left eye showing more drooping than the right [Figure 1]a. The ocular motility was full and free. The fatigue test and the Cogan's lid twitch sign were positive in both eyes, and an ice test showed marked improvement in ptosis [Figure 1]b. The serum level of antibodies against Ach-R was elevated (>8 nmol/L), and repetitive nerve stimulation at a low rate (3 Hz) showed a decremental response. Computed tomography of the chest ruled out the presence of a thymoma. He was administered oral pyridostigmine (60 mg thrice daily) under the supervision of a neurologist. A month later, in his follow-up visit, a good clinical response was observed to treatment. OMG is a localized form of autoimmune disorder characterized by antibodies against the Ach-Rs at the postsynaptic neuromuscular junction. The viral agents that have been implicated in MG are varicella, West Nile virus, and Zika virus.[3],[4] This is the third case of new-onset OMG following SARS-CoV-2 infection. The underlying pathogenesis postulated in COVID-19–induced MG is the cross-reaction of the antibodies produced against the virus with the Ach-R, due to molecular mimicry between the latter and the SARS-CoV-2 proteins. Moreover, on account of its affinity toward angiotensin-converting enzyme 2, it leads to activation of the inflammatory cascade which results in the production of autoantibodies.[2] Compared to the reported cases, our case developed ocular symptoms a little later, after 2 months of COVID-19 infection. By and large, all the COVID-19–induced OMG cases including this patient had demonstrated elevated serum levels of anti-Ach-R antibodies. Viral infection, in general, is a predisposing factor of MG crisis. Besides the cytokine dysregulation in COVID-19, the other contributory factors for SARS-CoV-2–related MG crisis are pandemic-induced stress, insomnia, anxiety, and hydroxychloroquine (directly known to cause MG) and the nonavailability of drugs during the lockdown. The stress caused by the pandemic triggers the inflammatory cascade.[5] However, none of these factors were contributory in our case.
Figure 1: (a) Mild ptosis in the right eye and severe ptosis in the left eye of the patient. (b) Resolution of bilateral ptosis after ice test

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed

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Conflicts of interest

There are no conflicts of interest.

   References Top

High B, Hixon AM, Tyler KL, Piquet AL, Pelak VS. Neurology and the COVID-19 pandemic: Gathering data for an informed response. Neurol Clin Pract 2021;11:e48-63.  Back to cited text no. 1
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;268:2690-6.  Back to cited text no. 2
Hawkes MA, Hocker SE, Leis AA. West Nile virus induces a post-infectious pro-inflammatory state that explains transformation of stable ocular myasthenia gravis to myasthenic crises. J Neurol Sci 2018;395:1-3.  Back to cited text no. 3
Molko N, Simon O, Guyon D, Biron A, Dupont-Rouzeyrol M, Gourinat AC. Zika virus infection and myasthenia gravis: ZReport of 2 cases. Neurology 2017;88:1097-8.  Back to cited text no. 4
Kalita J, Dongre N, Misra UK. Myasthenic crisis due to anxiety and insomnia during COVID-19 pandemic. Sleep Med 2020;75:532-3.  Back to cited text no. 5


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