D-dimer was also elevated at 300C600?ng/mL Fibrinogen Equivalent Units (FEU) (normal: less than 500?ng/mL FEU)

D-dimer was also elevated at 300C600?ng/mL Fibrinogen Equivalent Units (FEU) (normal: less than 500?ng/mL FEU). Additionally, if there is coexisting respiratory muscle weakness, MG patients can be at an increased risk of COVID-19-related complications [2]. In this case report, we discuss the presentation of a generalized MG exacerbation with co-existing COVID-19 symptoms and its management. 2.?Case report A 36-year-old female had been diagnosed with seronegative (acetylcholine receptor binding antibody negative and MuSk antibody negative) generalized MG via repetitive nerve stimulation two years ago when she presented with progressive limb weakness, fatigable ptosis, dysphagia and exertional dyspnea. At baseline, she was stable; her Myasthenia Gravis Activities of Daily living score (MG-ADL) was eight, and her Myasthenia Gravis Foundation of America (MGFA) class was 2A and MG-Composite was 13. Her last exacerbation was 6 months prior to this episode when she presented with worsening dysphagia and Pipequaline exertional dyspnea. She was treated with PLEX with significant improvement in symptoms. At the time of her current presentation, she was on Prednisone 25?mg daily for 4 months (was on 40?mg daily at diagnosis), Mycophenolate Mofetil 1000?mg twice daily (for 20 months) and Pyridostigmine 60?mg three times a day (for 24 months). She was also treated with maintenance IVIg every 10 weeks. She had undergone thymectomy about a year and half ago (thymic hyperplasia seen on biopsy). There was no other past medical history. The patient had a history of air travel to Massachusetts 10 days prior to symptom onset. She now presented with worsening ptosis, dysphagia, weakness and shortness of breath concerning for a MG exacerbation. In addition, she reported cough, fever and Pipequaline loss of sense of smell. Patient’s labs showed elevated white count (15.22??109/L) with lymphopenia (0.58??109/L). Respiratory pathogen panel including Influenza A/B and Streptococcus pneumonia came back negative. Given recent travel with cough and fever on presentation, she was tested for COVID-19 Real Time-Polymerase Chain Reaction primers (RT-PCR) with Centers for Disease Control (RT-PCR), which came back positive. Pulmonary function tests were deferred at that time, but an Arterial Blood Gas (ABG) Pipequaline showed PaO2 of 90?mmHg (normal: 75?mmHgC100?mmHg) and PaCO2 50mmg (normal: 35?mmHg-4 5?mmHg). She was admitted for management of her MG exacerbation symptoms. Her MG composite was 19. Her initial treatment regimen included supportive care for COVID-19 and PLEX for MG exacerbation. Pyridostigmine was held, but we continued mycophenolate in addition to Pipequaline stress dose IV steroids (oral prednisone was stopped). Three days after starting treatment, her respiratory status worsened. ABG done at that time showed PaO2 of 50? mmHg and PaCO2 of 60?mmHg, following which she was electively intubated. CT chest showed LECT bilateral ground-glass opacities (Fig. 1 ). Significant labs included an elevated aspartate transaminase 70 U/L (8C48 U/L), alanine transaminase 80 U/L (7C55 U/L), L-lactate dehydrogenase 300 U/L (122C222 U/L), and ferritin 400 micrograms/L (11C307 micrograms per liter). D-dimer was also elevated at 300C600?ng/mL Fibrinogen Equivalent Units (FEU) (normal: less than 500?ng/mL FEU). The patient remained intubated for the next 14 days during which she received PLEX therapy (a total of 5 exchanges done every other day) in addition to stress dose steroids. She remained in the hospital for an additional 7 days post extubation before being discharged to her home. She resumed her home dose prednisone (25?mg daily) and mycophenolate mofetil. Pipequaline