New-Onset Ocular Myasthenia Gravis After Booster Dose of COVID-19 Vaccine

Abstract

Coronavirus disease 2019 (COVID-19) vaccines have been reported as possible triggers of the production of antibodies pathogenic to the peripheral nerve and neuromuscular junction. We report on a patient who experienced vertical diplopia three weeks after the booster dose of the Pfizer-BioNTech vaccine (Comirnaty®). The diagnosis of myasthenia gravis (MG) was established based on highly positive antibodies to the nicotinic acetylcholine receptor (nAChR). Treatment with pyridostigmine and prednisone was started with gradually raising doses. On a follow-up exam two months after treatment initiation, clinical improvement was noted with an almost normal bulbomotor examination. The occurrence of diplopia following COVID-19 vaccination should raise suspicion of new-onset ocular MG and testing for anti-nAChR antibodies is advised.

Neuro-Ophthalmic Complications of COVID-19 Infection and Vaccination

“…New onset or exacerbation of ocular or generalized MG has been reported after BioNTech/Pfizer mRNA-vaccine BNT162b2, Moderna mRNA-1273, and AstraZeneca ChAdOx1 vaccines. ( 85 , 86 ) The age and gender of those patients mostly followed the demographic of the second peak of MG disease, which is commonly seen in men who are above 60 years of age( 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 ). Exacerbation of pre-existing MG post-vaccine is thought to be from 1-15%.…”

“…( 87 ) Ocular MG cases presented with intermittent fatigable ptosis and diplopia. ( 88 , 90 , 92 , 94 ) In some of the cases, associated symptoms occurred such as fatigue and weakness, myalgia, dysarthria, dysphagia, and head drop. ( 87 , 89 , 91 , 93 ) In 8 of the 11 patients acetylcholine receptors (AchR) antibodies was positive, but none were positive for anti-muscle-specific kinase (MuSK) antibodies.…”

“…( 87 , 89 , 91 , 93 ) In 8 of the 11 patients acetylcholine receptors (AchR) antibodies was positive, but none were positive for anti-muscle-specific kinase (MuSK) antibodies. ( 85 , 87 , 88 , 90 , 91 ) Electromyography was positive in 5 cases, showing either single-fiber electromyography (SFEMG) test of the orbicularis oculi identified with abnormal jitter or repetitive nerve stimulation providing diagnostic confirmatory for a postsynaptic neuromuscular junction disorder. ( 85 , 93 , 94 ) Computed tomography of the chest was negative except for one patient with mild thymic hyperplasia; interestingly, this case was double seronegative.…”

Medication Management in Patients with Polypharmacy

“…The usual cause is an acquired immunological abnormality, but some cases result from genetic abnormalities at the neuromuscular junction. Recently, a few studies suggest a possible correlation between COVID-19 vaccines or boosters and the development or worsening (crisis) of MG. A question arises about the triggering of antibodies influencing the neuromuscular junction (Abicic et al, 2022; Maher et al, 2022). Interestingly, Brian’s COVID-19 booster coincides with the onset of his MG ocular symptoms.…”

The safety of COVID-19 vaccines in patients with myasthenia gravis: A scoping review

“…presents detailed information of the included 18 case studies(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36) involving 48 patients. Twenty-eight of the 48 participants experienced the onset or flare of MG, and three of…”