To report a patient presenting with bulbar symptoms in the setting of COVID-19 infection leading to a new diagnosis of Myasthenia Gravis.

78 year old man presented to the hospital with new onset of dysphagia, dysarthria, bilateral ptosis and left facial droop. The patient was given intravenous alteplase for possible stroke. On admission the patient also tested positive for COVID-19. His symptoms persisted post-alteplase. On exam he was noted to have fatigable ptosis, weakness of brow elevation, eye closure, horizontal movements of the tongue and intermittent dysarthria, raising the concern for myasthenia gravis. A trial of Mestinon led to improved symptoms. Serum acetylcholine receptor antibodies were positive, confirming the Myasthenia Gravis diagnosis. He received 5 sessions of intravenous immunoglobulin (IVIG) due to persistent bulbar symptoms. He initially responded well to treatment but later decompensated with respiratory failure requiring intubation. He was then treated with plasmapheresis for 5 days with symptom improvement and was successfully extubated.

Our patient with a new diagnosis of myasthenia gravis with simultaneous COVID-19 infection eventually progressed into myasthenic crisis. This case raises the possibility of myasthenia and/or myasthenic crisis being a neurological complication of COVID-19 infection. Mechanisms behind this have been postulated to include molecular mimicry, the inflammatory cascade of COVID-19 leading to immune dysregulation, or viral illness triggering previously asymptomatic patients. Awareness of new onset myasthenia associated with COVID-19 infection can lead to earlier diagnosis and treatment.