Skip to main content
AAN.com
Invited Article
April 13, 2020
Letter to the Editor

COVID-19 and neuromuscular disorders

June 2, 2020 issue
94 (22) 959-969

Abstract

The coronavirus 2019 (COVID-19) pandemic has potential to disproportionately and severely affect patients with neuromuscular disorders. In a short period of time, it has already caused reorganization of neuromuscular clinical care delivery and education, which will likely have lasting effects on the field. This article reviews (1) potential neuromuscular complications of COVID-19, (2) assessment and mitigation of COVID-19-related risk for patients with preexisting neuromuscular disease, (3) guidance for management of immunosuppressive and immunomodulatory therapies, (4) practical guidance regarding neuromuscular care delivery, telemedicine, and education, and (5) effect on neuromuscular research. We outline key unanswered clinical questions and highlight the need for team-based and interspecialty collaboration. Primary goals of clinical research during this time are to develop evidence-based best practices and to minimize morbidity and mortality related to COVID-19 for patients with neuromuscular disorders.

Get full access to this article

View all available purchase options and get full access to this article.

References

1.
Zhao H, Shen D, Zhou H, Liu J, Chen S. Guillain-Barré syndrome associated with SARS-CoV-2 infection: causality or coincidence? Lancet Neurol Epub 2020 April 1.
2.
Kim JE, Heo JH, Kim HO, et al. Neurological complications during treatment of Middle East respiratory syndrome. J Clin Neurol 2017;13:227–233.
3.
Sharma K, Tengsupakul S, Sanchez O, Phaltas R, Maertens P. Guillain-Barré syndrome with unilateral peripheral facial and bulbar palsy in a child: a case report. SAGE Open Med Case Rep 2019;7:2050313X19838750.
4.
Turgay C, Emine T, Ozlem K, Muhammet SP, Haydar AT. A rare cause of acute flaccid paralysis: human coronaviruses. J Pediatr Neurosci 2015;10:280–281.
5.
Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497–506.
6.
Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA Epub 2020 Feb 7.
7.
Wang JT, Sheng WH, Fang CT, et al. Clinical manifestations, laboratory findings, and treatment outcomes of SARS patients. Emerg Infect Dis 2004;10:818–824.
8.
Fan CK, Yieh KM, Peng MY, Lin JC, Wang NC, Chang FY. Clinical and laboratory features in the early stage of severe acute respiratory syndrome. J Microbiol Immunol Infect 2006;39:45–53.
9.
Chen LL, Hsu CW, Tian YC, Fang JT. Rhabdomyolysis associated with acute renal failure in patients with severe acute respiratory syndrome. Int J Clin Pract 2005;59:1162–1166.
10.
Tsai LK, Hsieh ST, Chao CC, et al. Neuromuscular disorders in severe acute respiratory syndrome. Arch Neurol 2004;61:1669–1673.
11.
Leung TW, Wong KS, Hui AC, et al. Myopathic changes associated with severe acute respiratory syndrome: a postmortem case series. Arch Neurol 2005;62:1113–1117.
12.
Arabi YM, Deeb AM, Al-Hameed F, et al; the Saudi Critical Care Trials group. Macrolides in critically ill patients with Middle East respiratory syndrome. Int J Infect Dis 2019;81:184–190.
13.
Algahtani H, Subahi A, Shirah B. Neurological complications of Middle East respiratory syndrome coronavirus: a report of two cases and review of the literature. Case Rep Neurol Med 2016;2016:3502683.
14.
Torbic H, Duggal A. Neuromuscular blocking agents for acute respiratory distress syndrome. J Crit Care 2019;49:179–184.
15.
Gummi RR, Kukulka NA, Deroche CB, Govindarajan R. Factors associated with acute exacerbations of myasthenia gravis. Muscle Nerve 2019;60:693–699.
16.
Association of British Neurologists. Association of British Neurologists guidance on COVID-19 for people with neurological conditions, their doctors and carers. Published March 22, 2020. Available at: https://cdn.ymaws.com/www.theabn.org/resource/collection/6750BAE6-4CBC-4DDB-A684-116E03BFE634/ABN_Neurology_COVID-19_Guidance_22.3.20.pdf. Accessed on April 9, 2020.
17.
Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol 2020;21:335–337.
18.
Jacob S, Muppidi S, Guidon A, et al. Guidance for the management of myasthenia gravis (MG) and Lambert-Eaton myasthenic syndrome (LEMS) during the COVID-19 pandemic.J Neurol Sci 2020;412:116803.
19.
Prompetchara E, Ketloy C, Palaga T. Immune responses in COVID-19 and potential vaccines: lessons learned from SARS and MERS epidemic. Asian Pac J Allergy Immunol 2020;38:1–9.
20.
Fauci AS, Lane HC, Redfield RR. COVID-19: navigating the uncharted. N Engl J Med 2020;382:1268–1269.
21.
Lurie N, Saville M, Hatchett R, et al. Developing COVID-19 vaccines at pandemic speed. N Engl J Med Epub 2020 Mar 30.
22.
WHO Vaccine Blueprint [Internet]. 2020. Available at: https://www.who.int/blueprint/priority-diseases/key-action/novel-coronavirus-landscape-ncov.pdf. Accessed April 9, 2020.
23.
World Health Organization. Clinical Management of Severe Acute Respiratory Infection (SARI) When COVID-19 Disease Is Suspected. Geneva: World Health Organization; 2020:1–21.
24.
Martinez MA. Compounds with therapeutic potential against novel respiratory 2019 coronavirus. Antimicrob Agents Chemother Epub 2020 Mar 9.
25.
Cao B, Wang Y, Wen D, et al. A trial of lopinavir–ritonavir in adults hospitalized with severe covid-19. N Engl J Med Epub 2020 Mar 18.
26.
Ellis RJ, Marquie-Beck J, Delaney P, et al. Human immunodeficiency virus protease inhibitors and risk for peripheral neuropathy. Ann Neurol 2008;64:566–572.
27.
Vermaak JR, Dave JA, Levitt N, Heckmann JM. Sensory neuropathy and metabolic risk factors in human immune deficiency virus infected South Africans receiving protease inhibitors. AIDS Res Ther 2015;12:30.
28.
Arenas-Pinto A, Thompson J, Musoro G, et al; EARNEST Trial Team. Peripheral neuropathy in HIV patients in sub-Saharan Africa failing first-line therapy and the response to second-line ART in the EARNEST trial. J Neurovirol 2016;22:104–113.
29.
Benveniste O, Longuet P, Duval X, Le Moing V, Leport C, Vildé JL. Two episodes of acute renal failure, rhabdomyolysis, and severe hepatitis in an AIDS patient successively treated with ritonavir and indinavir. Clin Infect Dis 1999;28:1180–1181.
30.
Cheng CH, Miller C, Lowe C, Pearson VE. Rhabdomyolysis due to probable interaction between simvastatin and ritonavir. Am J Health Syst Pharm 2002;59:728–730.
31.
Mah Ming JB, Gill MJ. Drug-induced rhabdomyolysis after concomitant use of clarithromycin, atorvastatin, and lopinavir/ritonavir in a patient with HIV. AIDS Patient Care STDs 2003;17:207–210.
32.
de Kanter CT, Keuter M, van der Lee MJ, Koopmans PP, Burger DM. Rhabdomyolysis in an HIV-infected patient with impaired renal function concomitantly treated with rosuvastatin and lopinavir/ritonavir. Antivir Ther 2011;16:435–437.
33.
Wang M, Cao R, Zhang L, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res 2020;30:269–271.
34.
Mulangu S, Dodd LE, Davey RT Jr, et al. A randomized, controlled trial of Ebola virus disease therapeutics. N Engl J Med 2019;381:2293–2303.
35.
Cortegiani A, Ingoglia G, Ippolito M, Giarratano A, Einav S. A systematic review on the efficacy and safety of chloroquine for the treatment of COVID-19. J Crit Care 2020;9441:30390–30397.
36.
Guastalegname M, Vallone A. Could chloroquine/hydroxychloroquine be harmful in coronavirus disease 2019 (COVID-19) treatment? Clin Infect Dis Epub 2020 Mar 24. Letter.
37.
Gao J, Tian Z, Yang X. Breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies. Biosci Trends 2020;14:72–73.
38.
Eadie MJ, Ferrier TM. Chloroquine myopathy. J Neurol Neurosurg Psychiatry 1966;29:331–337.
39.
Joyce E, Fabre A, Mahon N. Hydroxychloroquine cardiotoxicity presenting as a rapidly evolving biventricular cardiomyopathy: key diagnostic features and literature review. Eur Heart J Acute Cardiovasc Care 2013;1:77–83.
40.
Mastaglia FL, Papadimitriou JM, Dawkins RL, et al. Vacuolar myopathy associated with chloroquine, lupus erythematosus and thymoma. J Neurol Sci 1977;34:315–328.
41.
Wasay M, Wolfe GI, Herrold JM, et al. Chloroquine myopathy and neuropathy with elevated CSF protein. Neurology 1998;51:1226–1227.
42.
Estes ML, Ewing-Wilson D, Chou SM, et al. Chloroquine neuromyotoxicity: clinical and pathological perspective. Am J Med 1987;82:447–455.
43.
Doughty CT, Amato AA. Toxic myopathies. Continuum 2019;25:1712–1731.
44.
Varan O, Kucuk H, Tufan A. Myasthenia gravis due to hydroxychloroquine. Reumatismo 2015;67:849.
45.
Jallouli M, Saadoun D, Eymard B, et al. The association of systemic lupus erythematosus and myasthenia gravis: a series of 17 cases, with a special focus on hydroxychloroquine use and a review of the literature. J Neurol 2011;259:1290–1297.
46.
Arabi YM, Harthi A, Hussein J, et al. Severe neurologic syndrome associated with Middle East respiratory syndrome corona virus (MERS-CoV) infection. 2015;43:495–501.
47.
Kwong JC, Vasa PP, Campitelli MA, et al. Risk of Guillain-Barré syndrome after seasonal influenza vaccination and influenza health-care encounters: a self-controlled study. Lancet Infect Dis 2013;13:769–776.
48.
Galeotti F, Massari M, D'Alessandro R,. Risk of Guillain-Barré syndrome after 2010-2011 influenza vaccination. Eur J Epidemiol 2013;28:433–444.
49.
Grave C, Boucheron P, Rudant J, et al. Seasonal influenza vaccine and Guillain-Barré syndrome: a self-controlled case series study. Neurology Epub 2020 Feb 25.
50.
Dodd CN, Romio SA, Black S, et al. International collaboration to assess the risk of Guillain Barré syndrome following influenza A (H1N1) 2009 monovalent vaccines. Vaccine 2013;31:4448–4458.
51.
De Wals P, Deceuninck G, Toth E, et al. Risk of Guillain-Barré syndrome following H1N1 influenza vaccination in Quebec. JAMA 2012;308:175–181.
52.
Crawford NW, Cheng A, Andrews N, et al. Guillain-Barré syndrome following pandemic (H1N1) 2009 influenza A immunisation in Victoria: a self-controlled case series. Med J Aust 2012;197:574–578.
53.
Polakowski LL, Sandhu SK, Martin DB, et al. Chart-confirmed Guillain-Barre syndrome after 2009 H1N1 influenza vaccination among the Medicare population, 2009-2010. Am J Epidemiol 2013;178:962–973.
54.
Salmon DA, Proschan M, Forshee R, et al. Association between Guillain-Barré syndrome and influenza A (H1N1) 2009 monovalent inactivated vaccines in the USA: a meta-analysis. Lancet 2013;381:1461–1468.
55.
Greene SK, Rett MD, Vellozzi C, et al. Guillain-Barré syndrome, influenza vaccination, and antecedent respiratory and Gastrointestinal infections: a case-centered analysis in the Vaccine Safety Datalink, 2009-2011. PLoS One 2013;8:e67185.
56.
Greene SK, Rett M, Weintraub ES, et al. Risk of confirmed Guillain-Barre syndrome following receipt of monovalent inactivated influenza A (H1N1) and seasonal influenza vaccines in the Vaccine Safety Datalink Project, 2009-2010. Am J Epidemiol 2012;175:1100–1109.
57.
AANEM COVID website [Internet]. 2020. Available at: aanem.org/Practice/COVID-19-Guidance. Accessed April 9, 2020.
58.
American Physical Therapy AssociationAvailable at: apta.org/telehealth/. Accessed April 9, 2020.
59.
Numotion [Internet]. 2020. Available at: numotion.com/medical-professionals/remote-evals-deliveries-service. Accessed April 9, 2020.
60.
Schwamm LH, Chumbler N, Brown E, et al. Recommendations for the implementation of telehealth in cardiovascular and stroke care: a policy statement from the American Heart Association. Circulation 2017;135:e24–e44.
61.
Keesara S, Jonas A, Schulman K. Covid-19 and health care's digital revolution. N Engl J Med Epub 2020 Apr 2.
62.
Paganoni S, Simmons Z. Telemedicine to innovate amyotrophic lateral sclerosis multidisciplinary care: the time has come. Muscle Nerve 2018;59:3–5.
63.
Govindarajan R, Anderson ER, Hesselbrock RR, et al. Developing an outline for teleneurology curriculum. Neurology 2017;89:951–959.
64.
Afshari M, Witek NP, Galifianakis NB. Education Research: an experiential outpatient teleneurology curriculum for residents. Neurology 2019;93:170–175.
65.
Donelan K, Barreto E, Sossong S, et al. Patient and clinician experiences with telehealth for patient follow-up care. Am J Manag Care 2019;25:40–44.
66.
Cohen BH, Busis NA, Ciccarelli L. Coding in the world of COVID-19: non–face-to-face evaluation and management care. Continuum 2020;26:1–25.
Letters to the Editor
20 April 2020
Reader response: COVID-19 and neuromuscular disorders
Tai-Heng Chen, Pediatric Neurologist | Kaohsiung Medical University Hospital, Kaohsiung Medical University
Jong-Hau Hsu, Pediatric Pulmonologist | Kaohsiung Medical University Hospital, Kaohsiung Medical University

We read with interest the comprehensive review by Guidon et al.1 It is given that respiratory compromises cause primary mortality of patients with neuromuscular disorders (NMD); however, we have not seen a more in-depth discussion regarding specific consideration for respiratory management of NMD patients with COVID-19 infection. Recently, the World Muscle Society advised features of NMD patients conferring a higher risk of severe COVID-19, mostly belonging to the pulmonary aspects.2

Modifications of respiratory care in NMD patients during the COVID-19 pandemic are urgently needed. Non-invasive ventilation (NIV) has been proposed as the first-line intervention of acute respiratory failure in NMD patients to avert intubation, shorter ICU stays, and improved survival.3 However, recent studies have restricted the NIV use during the COVID-19 pandemic for the concern of spreading the aerosolized virus.4 The design of a tight-fitting face mask with a viral-proof filter might be a solution. Several innovative designs have been proposed and applied clinically.5

Furthermore, periodic prone positioning is beneficial to improve the oxygenation of patients with COVID-19 complicated with acute respiratory distress syndrome (ARDS).4 However, this position might be challenging for NMD patients who are frequently associated with kyphoscoliosis.2

Nevertheless, COVID-19 is a rapidly evolving field, and the opinion of respiratory management in NMD patients is subject to frequent revision.

Disclosure

The authors report no relevant disclosures. Contact [email protected] for full disclosures.

References

  1. Guidon AC, Amato AA. COVID-19 and neuromuscular disorders. Neurology Epub 2020 Apr 13.
  2. Covid-19 and people with neuromuscular disorders: World Muscle Society position and advice. In: World Muscle Society. Available at: www.worldmusclesociety.org/news/view/150. Accessed April 20, 2020.
  3. Vianello A, Bevilacqua M, Arcaro G, Gallan F, Serra E. Non-invasive ventilatory approach to treatment of acute respiratory failure in neuromuscular disorders. A comparison with endotracheal intubation. Intensive Care Med 2000;26:384–390.
  4. Murthy S, Gomersall CD, Fowler RA. Care for Critically Ill Patients With COVID-19. JAMA 2020 Epub Mar 11.
  5. Easy-Covid19 Emergency mask for hospital ventilators. In: ISINNOVA. Available at: www.isinnova.it/easy-covid19-eng. Accessed April 20, 2020.

Information & Authors

Information

Published In

Neurology®
Volume 94Number 22June 2, 2020
Pages: 959-969
PubMed: 32284362

Publication History

Received: April 5, 2020
Accepted: April 9, 2020
Published online: April 13, 2020
Published in print: June 2, 2020

Permissions

Request permissions for this article.

Disclosure

A.C. Guidon has served as a consultant or on a medical advisory board for Alexion, Momenta, and Ra Pharma; has received royalties from Oakstone Publishing; and receives grant funding from the Myasthenia Gravis Foundation of America. A.A. Amato is Associate Editor for Neurology and received royalties from Oakstone Publishing, Neuromuscular Disorders, Harrison's Principles of Internal Medicine, and Up-to-Date, and has served as a consultant or on medical advisory board for Alexion and Argenx. Go to Neurology.org/N for full disclosures.

Study Funding

No targeted funding reported.

Authors

Affiliations & Disclosures

Amanda C. Guidon, MD
From the Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital (A.C.G.), and Division of Neuromuscular Medicine, Department of Neurology, Brigham and Woman's Hospital (A.A.A.), Harvard Medical School, Boston, MA.
Disclosure
Scientific Advisory Boards:
1.
(1) Alexion (2) Ra Pharma
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
(1) RaPharma (travel to investigator meeting) (2) Momenta Pharmaceuticals (travel to investigator meeting)
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
(1) Comprehensive Review of Neuromuscular and Electrodiagnostic Medicine, The Oakstone Institute, 2014, 2016 and 2018.
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
(1) Momenta Pharmaceuticals
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
1) Speaker honoraria (Massachusetts Neurologic Association) - CME activity
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
(1) RaPharma - Clinical trial (2) Momenta Pharmaceuticals - Clinical trial (3) Spouse employed by GE Healthcare
Research Support, Government Entities:
1.
1) PCORI - PROMISE MG Study - Site PI
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
1) Myasthenia Gravis Foundation of America Stock/Stock Options, Medical Equipment & Materials: Spouse owns General Electric (GE) stock, 2013 - present
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Anthony A. Amato, MD
From the Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital (A.C.G.), and Division of Neuromuscular Medicine, Department of Neurology, Brigham and Woman's Hospital (A.A.A.), Harvard Medical School, Boston, MA.
Disclosure
Scientific Advisory Boards:
1.
Medical Advisory Board for Alexion and Argenx
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
Associate Editor for Neurology
Patents:
1.
NONE
Publishing Royalties:
1.
Amato AA, Russell J. Neuromuscular Disease (2nd Ed). New York: McGraw-Hill, 2016 Harrisons Principles of Internal Medicine (2th ed), New Your, McGraw-Hill, 2018 Up-to-Date
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
Medical Consultant for Best Doctors
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
Expert witness for defendant in medical malpractice cases

Notes

Correspondence Dr. Guidon [email protected] or Dr. Amato [email protected]
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

Metrics & Citations

Metrics

Citations

Download Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Select your manager software from the list below and click Download.

Cited By
  1. Health-related quality of life (HRQoL) and psychological impact of the COVID-19 pandemic on patients with myasthenia gravis, Intractable & Rare Diseases Research, 12, 2, (88-96), (2023).https://doi.org/10.5582/irdr.2023.01003
    Crossref
  2. Association between Multimorbidity and COVID-19 Mortality in Qatar: A Cross-Sectional Study, Microbiology Research, 14, 1, (289-296), (2023).https://doi.org/10.3390/microbiolres14010023
    Crossref
  3. Impact of COVID-19 Era on the Anterior Cruciate Ligament Injury Rehabilitation: A Scoping Review, Journal of Clinical Medicine, 12, 17, (5655), (2023).https://doi.org/10.3390/jcm12175655
    Crossref
  4. COVID-19: a modern trigger for Guillain-Barre syndrome, myasthenia gravis, and small fiber neuropathy, Frontiers in Neuroscience, 17, (2023).https://doi.org/10.3389/fnins.2023.1198327
    Crossref
  5. Knowledge mapping of global trends for myasthenia gravis development: A bibliometrics analysis, Frontiers in Immunology, 14, (2023).https://doi.org/10.3389/fimmu.2023.1132201
    Crossref
  6. Immunogenicity of SARS-CoV-2 mRNA intramuscular vaccination in patients with muscular disorders, Frontiers in Immunology, 14, (2023).https://doi.org/10.3389/fimmu.2023.1103196
    Crossref
  7. Telemedicine in Neuromuscular Diseases During Covid-19 Pandemic: ERN-NMD European Survey, Journal of Neuromuscular Diseases, 10, 2, (173-184), (2023).https://doi.org/10.3233/JND-221525
    Crossref
  8. Association Between Guillain-Barré Syndrome and COVID-19 Infection and Vaccination, Neurology, 101, 20, (e2035-e2042), (2023)./doi/10.1212/WNL.0000000000207900
    Abstract
  9. Quality and Safety Analysis of 2,999 Telemedicine Encounters During the COVID-19 Pandemic, Neurology Clinical Practice, 11, 2, (e73-e82), (2023)./doi/10.1212/CPJ.0000000000001025
    Abstract
  10. Shortcomings of Rapid Clinical Information Dissemination, Neurology Clinical Practice, 11, 3, (e337-e343), (2023)./doi/10.1212/CPJ.0000000000000915
    Abstract
  11. See more
Loading...

View Options

Get Access

Login options

Check if you have access through your login credentials or your institution to get full access on this article.

Personal login Institutional Login
Purchase Options

Purchase this article to get full access to it.

Purchase Access, $39 for 24hr of access

View options

Full Text

View Full Text

Full Text HTML

View Full Text HTML

Media

Figures

Other

Tables

Share

Share

Share article link

Share