[Abstract]This study reports a case of an 83-year-old female patient with systemic severe myasthenia gravis (American Myasthenia Foundation class Ⅳb) and multiple comorbidities who achieved minimal clinical status through preoperative alemtuzumab treatment (10 mg/kg, once per week for 4 consecutive weeks). After undergoing robotic thymectomy, the patient remained clinically stable in the early postoperative period until the 5th day after surgery when she developed dysphagia. Despite intravenous immunoglobulin and other therapeutic interventions, the patient’s myasthenic symptoms continued to worsen, coughing was impaired, respiratory insufficiency intensified, non-invasive ventilation support was required, and pulmonary infection occurred. Clinical symptoms further deteriorated, with diarrhea, urinary tract infection, and progressive respiratory tract infection. She was subsequently transferred to the intensive care unit for invasive mechanical ventilation and therapeutic plasmapheresis. These interventions failed to halt the disease progression, which eventually led to multiple organ dysfunction syndrome, and the patient died. Notably, among the other 12 patients receiving alemtuzumab treatment during the same period, none experienced such severe complications. This case is exceptional, and a direct causal relationship between alemtuzumab and mortality risk cannot be established at this time. Further research is needed to clarify perioperative immune management strategies.
Objective To assess the clinical value of efgartigimod as a rapid induction therapy in the perioperative management of patients with myasthenia gravis (MG) undergoing thymectomy. Methods This retrospective study collected data from MG patients who underwent thymectomy at Myasthenia Gravis Diagnosis and Treatment Center, Shijiazhuang First People’s Hospital between October 2023 and July 2024. Patients were categorized into an efgartigimod group and a control group based on whether they received efgartigimod prior to thymectomy. Data collected included patient demographics (age at onset, sex), thymic pathology, preoperative immunosuppressant use, Myasthenia Gravis Foundation of America (MGFA) classification at 3 days pre- and 1 week post-surgery, postoperative complications, quantitative myasthenia gravis (QMG) scores, antibody titers, total IgG titers, and CD19+ B cell percentages. Hypothesis testing and multiple linear regression models were employed to analyze whether preoperative efgartigimod improved patient recovery. Results A total of 57 patients were included (16 males, 41 females), with a median age of 50 (35, 65) years, consistent with the typical MG demographic. Preoperative efgartigimod use was associated with a 38.0% reduction in postoperative QMG scores [adjusted β regression coefficient=0.38 (0.16, 0.60), adjusted P=0.001] and an increased likelihood of improvement in postoperative MGFA classification [adjusted OR=–1.98 (–3.08, –0.89), adjusted P<0.001]. Regarding immunological markers, preoperative efgartigimod was associated with significant reductions in postoperative total IgG levels [adjusted β regression coefficient=0.42 (0.30, 0.53), adjusted P<0.001] and antibody titers [adjusted β regression coefficient=0.27 (0.16, 0.38), adjusted P<0.001]. However, it had no significant effect on the proportion of CD19+ B cells [adjusted β regression coefficient=–1.37 (–3.26, 0.53), adjusted P=0.151]. Conclusion For MG patients undergoing thymectomy, preoperative efgartigimod treatment can significantly accelerate postoperative recovery and reduce postoperative total IgG and MG-related antibody levels.