COVID-19 Vaccination in Patients with Myasthenia Gravis: A Single-Center Case Series

Abstract

In this study, we report the safety of coronavirus disease 2019 (COVID-19) vaccine in patients with myasthenia gravis (MG). Patients who were vaccinated against COVID-19 were included. Demographics, clinical characteristics, medications, and vaccination information were collected. The main observation outcome is the worsening of MG symptoms within 4 weeks following COVID-19 vaccination. A total of 22 patients with MG vaccinated for COVID-19 were included. Ten (45.5%) patients had ocular MG (OMG), and 12 (55.5%) patients had generalized MG (GMG). Six (27.3%) patients were female, and the mean (SD) onset age was 45.4 (11.8) years. Nineteen (86.4%) patients were seropositive for acetylcholine receptors (AChR) antibody. Seven (31.8%) patients underwent thymectomy, and four of them confirmed thymoma pathologically. Twenty-one patients were administrated with inactivated vaccines, and the remaining one was administrated with recombinant subunit vaccine. Twenty (90.9%) patients did not present MG symptom worsening within 4 weeks of COVID-19 vaccination, and two (9.1%) patients reported slight symptom worsening but resolved quickly within a few days. Our findings suggest inactivated COVID-19 vaccines might be safe in MG patients with Myasthenia Gravis Foundation of America (MGFA) classification I to II, supporting the recommendation to promote vaccination for MG patients during the still expanding COVID-19 pandemic.

Vaccines and myasthenia gravis: a comprehensive review and retrospective study of SARS-CoV-2 vaccination in a large cohort of myasthenic patients

“…In particular, one patient reported mild neck muscle weakness 7 days after the first dose of recombinant subunit vaccine, whereas the second patient reported neck and limb weakness 20 days after the first dose of inactivated vaccine. In both cases, quick resolution of symptoms after pyridostigmine dose increase occurred [ 41 ].…”

“…Treatments included steroids, IVIg and thymectomy; only minimal disease manifestations persisted Tetanus Strijbos et al 2017 [ 36 ] 65 MG/LEMS pts (verum group), 23 MG pts (placebo group), 20 historical healthy controls Longitudinal prospective, placebo-controlled 4 weeks Anti-AChR, MuSK or VGCC titres remained unchanged 4 weeks after vaccination; moreover, no myasthenic exacerbations were registered. Tetanus revaccination is safe in MG/LEMS pts Neisseria Meningitidis (meningococcus) Tartof et al [ 39 ] 327 children aged 2–10 Retrospective observational 6–12 months Preliminary results showed 1 case of post-vaccine myasthenia gravis, subsequently refuted after physician investigator review Staphylococcus pneumoniae (23 polysaccharidic antigen pneumococcal vaccine) Nasca et al 1990 [ 40 ] 25 MG pts, 11 control pts Longitudinal prospective 28 ± 5 days Only minor local side effects were reported; all MG patients remained clinically stable, without exacerbations after vaccination SARS-CoV-2 (inactivated vaccine, adenovirus-vectored vaccine, recombinant subunit vaccine) Ruan et al 2021 [ 41 ] 22 MG pts Retrospective, single-centre case series 4 weeks after vaccination; 18 months for patients with symptom worsening 2/22 patients had mild and promptly-resolving worsening of MG symptoms SARS-CoV-2 (Moderna 1273 mRNA vaccine) Tagliaferri et al 2021 [ 42 ] 1 MG pt Case report (not specified) Bulbar and respiratory MG crisis 1 week after second dose of Moderna vaccine, requiring ICU transfer and intubation SARS-CoV-2 (Pfizer BNT162b2, Moderna 1273 mRNA and ChAdOx1 DNA vaccines) Watad et al 2021 [ 44 ] 27 subjects with immune-mediated diseases or flares within 28 days after SARS-CoV-2 vaccination Review structured as a multi-centre case series ...…”

Flare of myasthenia gravis induced by COVID-19 vaccines

“…Among the COVID-19 vaccines, the mRNA vaccines, BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna), and the viral vector vaccine, ChAdOx1-S (AstraZeneca), are available in Japan. However, it remains unclear whether these vaccines cause flare of existing myasthenia gravis (MG) [ [2] , [3] , [4] ].…”

A Comprehensive Review of Neuromuscular Manifestations of COVID-19 and Management of Pre-Existing Neuromuscular Disorders in Children

“…Regarding vaccination, evidence for safety and efficacy in myasthenia gravis is currently limited. A single-center case series of 22 adult myasthenia patients supports the safety of vaccination in patients with Myasthenia Gravis Foundation of America (MGFA) classification I to II disease [64]. Limited evidence is available regarding the efficacy of vaccination in these patients [19], as so-called fragile patients with malignancy, neurological and immunological disorders were excluded from vaccination trials.…”