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• Rituximab for Myasthenic Crisis
  Marcelo D. Schafranski
  Published on: 24 May 2010

• Published on: 24 May 2010

  Rituximab for Myasthenic Crisis

  • Marcelo D. Schafranski, Medical Doctor, Intensive Care Unit
  • Other Contributors:
    • Carlos Arnaldo Medaglia, Cinthia Medaglia, Delcio Bertucci, Derly T. Ferraz

  It was with great interest that we read the article published in the Journal where rituximab was successfully used to treat myasthenia gravis refractory cases (1). Here, we describe a case where the drug was administered in a difficult-to treat-myasthenic crisis. A 65-year-old woman who suffered from myasthenia gravis since 2006 was admitted to the intensive care unit (ICU) in severe respiratory distress. The patient was...

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  It was with great interest that we read the article published in the Journal where rituximab was successfully used to treat myasthenia gravis refractory cases (1). Here, we describe a case where the drug was administered in a difficult-to treat-myasthenic crisis. A 65-year-old woman who suffered from myasthenia gravis since 2006 was admitted to the intensive care unit (ICU) in severe respiratory distress. The patient was well until two weeks before admission, when she was vaccinated against influenza H1N1. Seven days later, progressive muscle weakness developed and the patient searched for medical assistance in an emergency situation. Until then, the disease was well-controlled with pyridostigmine 60 mg qid. The patient had a previous 40-day ICU admission two months before also due to a myasthenic crisis triggered at that time by a perforated and infected cholecystitis, which improved after colecistectomy and resolution of the infectious process. The disease was positive for anti-acetylcoline receptor antibodies (titles not available). On admission, orotracheal intubation and mechanical ventilation were needed. Hydrocortisone (100 mg IV tid) and neostygmine (0.06 mg/kg/hour under continuous IV infusion) were started. After two weeks, no improvement on muscle strenght was observed and the patient remained on mechanical ventilation. Based on recent literature findings (1) and after a husband's informed consent was obtained, weekly infusions of rituximab (375 mg per square meter of body surface) was started. Right before the third infusion, global muscle strength improvement was observed, allowing weaning from the mechanical ventilation. One day after the third infusion, the patient was discharged from the ICU. Rituximab is a chimeric monoclonal antibody against CD20 B- lymphocytes. It is FDA-approved for the treatment of Hodgkin's lymphoma and rheumatoid arthritis, but a growing body of evidence supports its use in several auto-immune diseases where humoral immunity plays a pivotal role, such as systemic lupus erythematosus and Sjogren syndrome (2). Recent evidence reveals promissing results for rituximab in refractory cases of myasthenia gravis. Here, the administration of the drug in an ICU setting was safe and effective, as previosly reported by Sadnicka and colleagues (3). Further studies are warranted in order to establish rituximab as a therapeutic alternative also for severe cases of myasthenic crisis.

  1.Maddison P, McConville J, Farrugia ME et al. The use of rituximab in myasthenia gravis and Lambert-Eaton myasthenic syndrome. J Neurol Neurosurg Psychiatry 2010 (Epub ahead of print).

  2.Furst DE, Keystone EC, Fleischmann R et al. Updated consensus statement on biological agents for the treatment of rheumatic diseases, 2009. Ann Rheum Dis 2010;69 Suppl 1:i2-29.

  3.Sadnicka A, Reillt MM, Mummery C et al. Rituximab in the treatment of three coexistent neurological autoimmune diseases: chronic inflammatory demyelinating polyradiculoneuropathy, Morvan syndrome and myasthenia gravis. J Neurol Neurosurg Psychiatry 2010 (Epub ahead of print).

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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