De Novo Onset of Myasthenia Gravis after Kidney Transplantation

Myasthenia gravis occurring de novo after kidney transplantation is a rare course of severe muscle weakness. A 57-year-old female on treatment with peritoneal dialysis following polycystic kidney disease received a renal transplant with standard basiliximab induction. She had no preceding history of neuromuscular problems. Three months after transplant she presented with progressive weakness and fatigability, finally needing a wheelchair to mobilise. Graft function was stable. Examination revealed patchy limb weakness, worsening on repeated exercise. There were no abnormalities in cranial nerves, reflexes, or sensation. Electromyography was normal, but repetitive nerve stimulation studies showed a postsynaptic neuromuscular transmission defect suggestive of myasthenia gravis. Serological testing revealed no putative antibodies. Initial treatment with pyridostigmine was not tolerated. Following an episode of hospitalisation with severe limb weakness, she received intravenous immunoglobulin and showed dramatic improvement, which persisted over the next few weeks. Approximately 6 months later, she had a relapse of her symptoms, which once again responded to intravenous immunoglobulin therapy. De novo myasthenia gravis after transplantation is a rare entity, infrequently reported in the literature. This illness is surprising since immunosuppression after transplant is usually sufficient to prevent immune-mediated disease. This patient had no history of similar illnesses. Delayed physical recovery after major surgery such as renal transplantation is often attributed to other causes such as deconditioning, and patients are often prescribed physiotherapy as a response. In this patient, the profound unexplained weakness that persisted for several weeks after transplant prompted referral to the neurologist, which enabled this rare diagnosis to be made. This story highlights the need to monitor unexpected symptoms closely and to consider a wide differential diagnosis when improvement after transplant is not along usual expected lines. Finally, this case also illustrates the benefits of multidisciplinary involvement in the care of these complex patients.