A Rare Case of Chronic Lymphocytic Leukemia Complicated by Myasthenia Gravis.

Abstract

Introduction: About 10-25 % of chronic lymphocytic leukemia (CLL) patients experience complications related to autoimmune activity. Although less common, non-hematological autoimmune manifestations have been observed. Myasthenia gravis (MG) is rarely found in association with CLL. Since 1967, only 27 publications have reported the association between CLL and MG, encompassing just 15 cases. Our case is particularly notable for the refractory nature of the patient's MG.

Case presentation: A 56-year-old male with Rai Stage II CLL and myasthenia gravis presented to the emergency department with respiratory distress, dysphagia, and weakness. He was admitted for treatment with intravenous immune globulin, pyridostigmine, and intravenous solumedrol. Notably, the patient was diagnosed with CLL approximately three months prior and MG just one week before presentation. Despite aggressive treatment, the patient's myasthenia gravis symptoms persisted, prompting suspicion of CLL-related complications. Due to the patient's refractory myasthenia gravis, weekly rituximab 375 mg/m2 was initiated. He was given the first dose of rituximab during the hospital admission after which his dysphagia clinically improved.Outpatient management included obinutuzumab and Ventoclax for CLL control, resulting in gradual resolution of MG symptoms over a few months.

Discussion: Patients with myasthenia gravis (MG) generally do not require routine leukemia screening unless factors such as lymphadenopathy, splenomegaly, or refractory MG warrant further evaluation. Conversely, symptoms like ptosis in chronic lymphocytic leukemia (CLL) should prompt MG assessment. Early CLL treatment, as seen in this case, can resolve neurological symptoms and achieve remission, highlighting the need for a timely diagnosis and intervention to enhance patient outcomes.