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 48-year-old gentleman, diagnosed as anti-MuSK-positive MG at another center, was on treatment with steroids and pyridostigmine. He presented to our emergency services with shortness of breath. Five cycles of plasma exchange followed by a course of IVIG were given without improvement. He was then given IV rituximab (375 mg/m2 weekly for 4 weeks) and he had complete resolution of symptoms. Steroids were tapered and stopped. He is in remission for the past 1½ year and is on intermittent pulses of rituximab.