After obtaining the approval of the local ethics committee (Section Giovanni Paolo II- IRCCS Casa Sollievo della Sofferenza) and written informed consent, we report the case of a 66-year-old man with a history of hypertension and ocular MG. This disorder was diagnosed 2 years before the pandemic onset by electromyography (EMG) and frontal muscle jitter study at the neurology unit of our hospital (Figure 1). AChR antibodies were detected, and and the thymoma ascertainment results were negative. He undertook pharmacology therapy consisting of pyridostigmine at a dosage of 30 mg three times daily, which was efficacious in treating myasthenic symptoms. The strength quantification performed by the Medical Research Council (MRC) was normal before the pandemic. At the beginning of December 2020, he developed fever, cough, myalgia, and dyspnea with progressive severe respiratory failure, which required ICU admission. He underwent chest computer tomography (CT) and nasopharyngeal swab that were positive for COVID-19 and was treated with remdesivir and corticosteroids. The patient underwent mechanical ventilation and tracheotomy. Laboratory tests did not detect an increase in the serum CK level. He also developed infections caused by multi-drug resistant germs, including Klebsiella pneumonia, Acinetobacter baumannii, and Pseudomonas aeruginosa, and underwent multiple antibiotic therapies. The Simplified Acute Physiology Score was 35. During the ICU stay, 15 days after admission, he complained of muscle weakness that evolved into the manifestation of tetraparesis without ocular involvement. Despite this development, pyridostigmine was increased to 60 mg three times daily; the strength remained unchanged. The length of stay (LOS) in ICU was 35 days. After improvement of the clinical conditions, the patient was transferred to our neuro-rehabilitation (NR) unit. At admission, the patient breathed spontaneously but needed 3 L/m oxygen by mask. Capillary oximetry was 97%; he had a central venous catheter, a tracheal tube, and a nasal-gastric tube for nutrition. The neurological picture showed severe tetraparesis that involved predominantly the lower limbs, and he had absent tendinous reflexes. No deficit in ocular or facial muscles was detected, and superficial and deep sensibilities were normal. Given the neurological feature, on day 2 of admission, the patient underwent electroneurography (ENG), electromyography (EMG), and frontal muscle jitter study that confirmed MG and showed overlapping ICUAW. In this respect, the electrophysiological exam revealed signs characteristic of CIP (Table 1). However, a lumbar puncture was performed, and cerebrospinal fluid (CSF) was collected and processed for standard analysis to exclude Guillain-Barre syndrome and polyneuropathies of different etiology. Pressure, cell count, and protein levels (<45 mg/dl) of the CSF were normal without albumin-cytologic disassociation. CSF/serum glucose ratio was normal. The CSF culture results for possible organisms, such as human immunodeficiency virus, hepatitis B virus, hepatitis C virus, bacteria, Mycobacterium tuberculosis, fungi, Borrelia, enteroviruses, Herpes viruses, and CMV, were negative. Similarly, the laboratory test for autoimmune disorders, including lupus anticoagulant, anticardiolipin antibodies, a panel of antiganglioside antibodies, including anti-GM1, -GM2, -GM3, -GD1a, -GD1b, -GT1b, and -GQ1b, and a panel for paraneoplastic syndrome, were negative.
Strength and functional evaluation were quantified through the MRC scale sum-score, the Disability Rating scale (DRS), the Barthel scale (BS), and the functional independence measure (FIM) at admission, discharge, and 6 months of follow-up. During NR stay, the patient underwent a personalized and tailored rehabilitation treatment for 3 h daily, 6 days a week. Furthermore, he performed 2 h of daily electrical muscular stimulation on the lower limbs by placing surface electrodes on the quadriceps and anterior tibial muscles bilaterally. The muscular strength improved progressively, and the MRC sum score was 50 at discharge. The anticholinesterase therapy with pyridostigmine at the dosage of 30 mg three times daily, the same that the patient was taking before he had COVID-19, was resumed. His motor abilities recovered and, at discharge, he was able to walk without support but remained with left foot drop, which required the application of an ankle-foot orthosis (AFO). Furthermore, he complained of mild fatigue with reduced endurance, which improved over time. At follow-up, the MRC scale sum score and all functional scale scores resulted to be normal (Table 2). The LOS in neuro-rehabilitation was 42 days.