A 47-year-old gentleman presented a with 2-year history of bilateral ptosis, diplopia, and bulbar weakness. Neostigmine test and RNS were positive, while CECT of the chest was normal. Anti-AChR antibody was negative. Symptoms responded to steroids, pyridostigmine, and azathioprine. He was well for the next 2 years when he had developed severe bulbar weakness and respiratory difficulty. Anti-MuSK was positive, and five cycles of plasma exchange were administered with no response. IV rituximab was then started with good response after two doses, steroids and immunomodulation were tapered, and rituximab was given weekly for 4 weeks every 6 months. He is symptom free on 2-year follow-up.
A 58-year-old female presented with a 1-month history of bulbar symptoms in the form of difficulty in swallowing and speaking. Anti-MuSK antibodies were positive. CECT of the chest was normal. She was treated with five cycles of plasma exchange followed by IVIG. She had persistent bulbar weakness after 1 month of the above treatment, so she was administered IV rituximab. She improved remarkably, with almost complete resolution of her bulbar and other symptoms. She is doing well at 8-month follow-up.