Recurrent Myasthenic Crisis Triggered By Infection: Successful Management With Plasmapheresis

Abstract

Introduction: Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction characterized by fluctuating skeletal muscle weakness. The most severe complication is myasthenic crisis (MC), defined as acute respiratory failure requiring ventilatory support, which occurs in up to 20% of patients during the disease course. Infections are the most frequent precipitating factor, complicating diagnosis and worsening prognosis. Plasmapheresis (therapeutic plasma exchange, TPE) is an effective therapy that provides rapid clinical improvement in acute management.

Case series: We report a 46-year-old woman with recently diagnosed generalized MG who experienced recurrent MC three weeks after hospital discharge. In her first admission, she developed acute respiratory failure requiring intubation, intensive care, and three sessions of plasmapheresis. On the second admission, she presented with progressive shortness of breath, hoarseness, dysphagia, fever, productive cough, and headache. She had stopped pyridostigmine due to dysphagia. Physical examination showed ptosis, limb weakness, and hypoxemia, while chest radiography revealed pneumonia. Despite oxygen therapy, her respiratory function deteriorated rapidly, leading to intubation and mechanical ventilation. Management included broad-spectrum antibiotics, ventilatory support, and two additional sessions of plasmapheresis, which resulted in significant improvement in both respiratory and neurological function. She was discharged in stable condition after 17 days of hospitalization.

Conclusion: This case underscores the diagnostic and therapeutic challenges of recurrent MC triggered by infection. Prompt recognition, timely initiation of plasmapheresis, and multidisciplinary care are crucial in reducing morbidity and mortality. Preventive measures, adherence to immunosuppressive therapy, and infection control are essential to minimize recurrence and improve long-term outcomes