Disclosures: Lauren M. Cuenant, DO: No financial relationships or conflicts of interest

Case Diagnosis: Managing myasthenia gravis (MG) crisis and preventing prolonged hospital stay in a patient with recent surgery and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia via intravenous immune globulin (IVIG) infusion during inpatient rehabilitation.

Case Description or Program Description: A 62-year-old male with past medical history of MG, human immunodeficiency virus, osteoporosis, Sjogren’s disease, diabetes, peripheral artery disease, and prior left above the knee amputation was admitted to inpatient rehabilitation following SARS-CoV-2 pneumonia, right lower extremity bypass grafting and right great toe amputation secondary to worsening peripheral vascular disease and gangrene. Course was notable for worsening lethargy, vision complaints, and supplemental oxygen requirement. Physical exam was below baseline and notable for bilateral fatiguable ptosis with curtain sign, positive Cogan lid twitch, and eye closure muscle strength graded 4+/5. Patient responded well to IVIG infusion for suspected myasthenic crisis. Patient later developed scrotal lesions which were treated with intravenous acyclovir given high suspicion of herpes simplex virus in the setting of immunosuppression.

Setting: Inpatient Rehabilitation

Assessment/Results: Patient received 5 days of IVIG infusion for myasthenic crisis secondary to recent surgery and SARS-CoV-2 pneumonia. Despite multiple complications, the patient did not require transfer to acute care for medical management and met inpatient goals prior to discharge.

Discussion (relevance): During the pandemic, rehabilitation facilities have noted more cases complicated by the effects of concomitant SARS-CoV-2 infection and the impact it has on the immunosuppressed population. Of note, double insults like surgery and infection can trigger flares in patients with autoimmune diseases. This case highlights the benefits of providing comprehensive resources during inpatient rehabilitation to avoid disruption of care, prolonged hospitalization, and additional costs.

Conclusions: This case study demonstrates the higher level of medical diagnosis and management capable in the acute inpatient rehabilitation setting to facilitate a complex patient’s rehabilitation course without interruption.

Level of Evidence: Level IV

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/management-of-myasthenic-crisis-triggered-by-surgery-and-concomitant-sars-cov-2-infection-via-ivig-infusion-during-inpatient-rehabilitation/