Background: Myasthenia gravis, the most common autoimmune disease affecting the neuromuscular junction, is characterized by generalized muscle weakness. Myasthenia is easily treated, yet social determinants of health can complicate a patient’s access to treatment, prolonging symptoms and increasing patient suffering. Further, residents of rural Maine struggle with healthcare access, as 40% of Mainers live in rural areas and 6% of Mainers are uninsured. 

Case Presentation: A 29-year-old female presented to our hospital’s emergency department from her neurologist’s office. She presented with four months of neck and limb weakness and dysphagia; these symptoms worsened throughout the day. She recently had left her job, as she could no longer perform her duties due to weakness. A resident of rural Maine without health insurance who did not qualify for Medicaid, this patient had not seen a primary care provider (PCP) in five years. She was previously evaluated in an urgent care for similar symptoms and was advised to consult a PCP for further work-up. It took two months for the patient to secure a PCP; she was referred to a neurologist who immediately sent her to the emergency department.

On examination, the patient’s strength was globally 3/5. She was hyporeflexive. She ambulated with a walker. A workup for a neuromuscular syndrome was started. A chest CT did not show a thymoma. The patient was admitted to the hospital, where she was seen by neurology and started on pyridostigmine; she demonstrated immediate improvement. She was discharged one day later with a diagnosis of myasthenia and inflammatory motor neuropathy.

On follow-up with her neurologist one month later, the patient reported mild improvement with pyridostigmine. IV immunoglobulin (IVIG) therapy was ordered to treat her motor neuropathy. However, the patient was still unable to secure insurance, and IVIG therapy was delayed two months. Three months post-discharge, the patient secured insurance and began treatment with IVIG infusions. 

Discussion: The most salient aspect of this case is the patient’s social determinants of health – specifically lack of health care access. This case highlights the disparities that exist for underinsured adults and the great need for PCPs, especially in rural areas. Further, myasthenia is easily treated, yet the patient’s delay in treatment played an enormous impact on her physical and social wellbeing. This case serves to underline the consequences of limited PCP availability and insurance access which prolongs physical and social suffering for conditions with clear treatment, such as the myasthenia demonstrated in this case. 


Myasthenia Gravis Complicated by Lack of Healthcare Access in Rural Maine

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