COVID-19 and Neuromuscular Issues
No direct causality is established. It will need large epidemiological studies
Viral myositis is implicated.
Very sick patients can develop CIM and CIP.
Disuse atrophy secondary to severe physical deconditioning following severe COVID-19 infection requiring prolonged ICU care.
GBS
A paper from Italy reported increased risk of GBS. People were infected with COVID-19 had a 6 fold increase in the risk of developing Guillain-Barre syndrome over noninfected people.
A paper published in Brain from UK reported that there is no risk of GBS
Unmaking of underlying neuromuscular disease - hypothesis.
Patients with motor neuron disease (e.g., amyotrophic lateral sclerosis [ALS], spinal muscular atrophy) and hereditary neuropathies with ventilatory muscle involvement may be particularly susceptible to infection.
Metabolic myopathies (e.g., lipid storage diseases and mitochondrial disorders) are at increased risk of rhabdomyolysis with fever, infection, or fasting (attributable to loss of appetite).
Autoimmune disorders such as CIDP, MADSAM, MMN, MG, LEMS, myositis.
Muscular dystrophies, including myotonic dystrophy, and metabolic diseases (e.g., Pompe disease) who have ventilatory muscle weakness or cardiomyopathy are likely at increased risk for severe COVID-19.
Patients who develop COVID-19 may not return to their prior baseline.
Risks of immunosuppressant/immunomodulating therapies in patients with autoimmune NMD
Increased risk of COVID-19 infection and more severe disease
Immunosuppression can allow the virus to go unchecked leading to fatal outcome
Cancer patients are especially susceptible.
Rituximab and other B cell depleters can impair priming of antibody response to neutralize viral replication and explain some of the unfavorable outcomes amongst COVID-19 patients.
Do not use rituximab unless it is a MuSK MG patient.
Steroid IV, IVIg, complement inhibitor therapy (e.g., eculizumab), therapeutic plasma exchange, or neonatal Fc receptor (FcRn) antagonists are expected not to increase the risk of COVID-19 infection or severe disease.
Patients with NMD already on corticosteroids may require stress doses.
Typically, other immunosuppression is held or continued based on the patient’s clinical status from COVID-19 and the severity of their underlying NM
Increased risks and severity of other infections in patients with COVID-19 in the setting of NMD treated with certain immunotherapies.
Immunotherapies might make vaccines less effective
Risks of treatments for COVID-19
Hydroxychloroquine and chloroquine can cause a toxic neuropathy and myopathy
Antiviral treatments: lopinavir/ritonavir, remdesivir, others.
Risks of vaccinations
Possible inflammatory neuropathy (e.g., Guillain-Barre syndrome, plexitis, mononeuritis)
Timing of vaccine around initiation of rituximab: complete vaccine series at least 2 weeks prior to starting rituximab.
If patient already received rituximab, postpone vaccine for 4 months.
Patient on IVIg today, do not give vaccine tomorrow. Postpone it to mid-cycle.
Patient with history of GBS, Bell's palsy: not a contraindication to COVID-19.
Live vaccine must be avoided.
mRNA vaccine does not increase the risk of Guillain-Barre but in fact the visit.