Background
Myasthenia gravis is classically described in the literature as an autoimmune disorder with antibodies directed at the acetylcholine receptor on the motor end plate. This autoimmune destruction of these key areas of the interface between the nervous system and the musculoskeletal system leads to weakness and fatigue in patients. Rarely in the literature has this been described as a molecular mimicry event secondary to viral illnesses like that of COVID-19. 

Case Report
Herein the authors describe the case of a 71-year-old right-handed female who presented with key symptoms of dyspnea, drooping eye lids, difficulty lifting her neck, dysphagia, slurring of speech, bilateral shoulder weakness, and needing to change eating positions due to discomfort of her shoulders and arms. The patient endorsed her eyelid drooping worsened in the later part of the day such that she had to tape her eyelids open in order to see. The patient underwent ice testing, trial of pyridostigmine, was discharged with a prescription for prednisone and pyridostigmine, set up with outpatient follow up, and was given a working diagnosis of COVID-19 induced myasthenia gravis.

Discussion
This case is important as it highlights three key lessons of importance within the literature on myasthenia gravis. First is the transient worsening of a patient when given corticosteroids. In high doses, steroids can worsen or send a person into myasthenic crisis which is the reason that they should not be utilized as primary treatment in crisis. Second is the etiology of myasthenia gravis, often there is not found an antecedent event in patients, however, the history of this case made it clear that this was likely a molecular mimicry event secondary to a COVID-19 infection. Thus, the authors desire to remind the readership of the importance of a thorough history and physical examination. Lastly, as a part of the diagnostic work up, the clinicians utilized an older physical examination maneuver known as the ice test. When utilized, this test has a high negative predictive value and therefore still has a place in bedside diagnostics when ruling out myasthenia gravis.

"It's been downhill since COVID": Myasthenia Gravis secondary to COVID Infection

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