Dengue Fever in Myasthenic Crisis
Alif Adlan Mohd Thabit *
Department of Medicine, Bentong Hospital, Jalan Tras, 28700 Bentong, Pahang, Malaysia.
Wan Mohd Rasis Wan Ahmad Kamil
Department of Medicine, Bentong Hospital, Jalan Tras, 28700 Bentong, Pahang, Malaysia.
Mohd Ramadhan Mohd Din
Department of Medicine, Sultan Haji Ahmad Shah Hospital, Jalan Maran, 28000 Temerloh, Pahang, Malaysia.
*Author to whom correspondence should be addressed.
Abstract
Aims: To investigate the possibility of a difference in late response towards intravenous immunoglobulin and its efficacy in myasthenic crisis when given during an acute dengue infection.
Presentation of Case: We report a 29-year old lady with myasthenia gravis diagnosed two years prior based on clinical presentation and positive anti-cholinesterase receptor antibody (AChR Ab) titre of > 20.98 nmol/L. Dengue infection was confirmed with positive SD® Dengue NS1 (Non Specific-1) antigen test. Muscle strength graded with the Medical Research Council (MRC) scale as well as hematological tests and arterial blood gases were done with chest X-rays to investigate for a concurrent chest infection. The patient was given IVIg) 0.4 g/kg/day for five days on the fifth day during the febrile phase of dengue fever after being ventilated in ICU for severe type 2 respiratory failure.
Discussion: The patient showed neurological improvement only after twenty five days post-IVIg administration due to ventilator associated pneumonia and Stenotrophomonas maltophilia bacteraemia as post viral complications, as compared to five days during her previous uncomplicated myasthenic crisis. From a muscle power of 4/5 bilaterally of upper and lower limb extremities it had improved to 5/5 bilaterally together with improving hematological blood counts which coincides with the resolution of dengue and bacterial infections.
Conclusion: The delay in response towards IVIg in this myasthenic crisis is multifactorial – including the patient’s non-compliance to therapy, the dengue viraemia as well as the concomitant pneumonia which occurred during the later stage of the dengue infection. A future alternative option of plasma exchange should be looked into detail.
Keywords: Dengue fever, myasthenia gravis, myasthenic crisis, IVIg, intravenous immunoglobulin