Fever of unknown origin in patient with myasthenia gravis following laparoscopic adrenalectomy—a case report
DOI:
https://doi.org/10.14748/8srv4s39Keywords:
myastenia gravis, laparoscopic adrenalectomy, fever of unknown origin, adrenal adenomaAbstract
Introduction
Myasthenia gravis is a rare autoimmune neuromuscular disorder caused by antibodies that impair signal transmission at the neuromuscular junction. Patients are at increased risk of perioperative complications and may exhibit atypical responses to surgical stress. Postoperative fever is commonly attributed to infection, but in such individuals, non-infectious causes must also be considered.
Aim
The aim of this article is to describe a case of fever of unknown origin (FUO) following laparoscopic adrenalectomy in a patient with myasthenia gravis and to discuss diagnostic considerations and management.
Case Report
A 40-year-old woman with myasthenia gravis underwent laparoscopic adrenalectomy for adrenocorticotropic hormone (ACTH)-independent Cushing’s syndrome. Preoperative computed tomography (CT) revealed a right adrenal mass consistent with adenoma. Postoperatively, she developed persistent fever without clinical, laboratory, or imaging evidence of infection or endocrine disturbance. Extensive investigations, including microbiological tests, imaging, and specialist consultations, were inconclusive. Neurogenic or autoimmune thermoregulatory dysfunction induced by surgical stress was considered.
Discussion and Conclusion
This case highlights the complexity of evaluating postoperative fever in patients with autoimmune neuromuscular disorders. Differential diagnosis should extend beyond sepsis to include immune and neurological factors. Early recognition and individualized, multidisciplinary management are crucial for optimal outcomes.
References
[1] Conti-Fine BM, Milani M, Kaminski HJ. Myasthenia gravis: past, present, and future. J Clin Invest. 2006 Nov;116(11):2843–54. doi: 10.1172/JCI29894. DOI: https://doi.org/10.1172/JCI29894
[2] Gilhus NE, Verschuuren JJ. Myasthenia gravis: subgroup classification and therapeutic strategies. Lancet Neurol. 2015 Oct;14(10):1023–36. doi: 10.1016/S1474-4422(15)00145-3. DOI: https://doi.org/10.1016/S1474-4422(15)00145-3
[3] Beloor Suresh A, Asuncion RMD. Myasthenia Gravis. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559331/
[4] Howard JF Jr. Myasthenia gravis: the role of complement at the neuromuscular junction. Ann N Y Acad Sci. 2018 Jan;1412(1):113-128. doi: 10.1111/nyas.13522. DOI: https://doi.org/10.1111/nyas.13522
[5] Jowkar A. Myasthenia Gravis: Practice Essentials, Background, Anatomy [Internet]. Medscape; 2019 [cited 2025 Jun 25]. Available from: https://emedicine.medscape.com/article/1171206-overview
[6] Engel AG. Myasthenia gravis and myasthenic disorders. In: Warrell DA, Cox TM, Firth JD, editors. Oxford Textbook of Medicine. 5th ed. Oxford: Oxford University Press; 2012.
[7] Hattori S, Miyajima A, Maeda T, et al. Risk factors for perioperative complications of laparoscopic adrenalectomy including single-site surgery. J Endourol. 2012 Nov;26(11):1463-7. doi: 10.1089/end.2012.0274. DOI: https://doi.org/10.1089/end.2012.0274
[8] Izawa M, Takeda T, Anno T, et al. Risk factors for postoperative fever after laparoscopic adrenalectomy focusing on hormones produced: a case control study. BMC Urol. 2024 Apr 18;24(1):90. doi: 10.1186/s12894-024-01469-w. DOI: https://doi.org/10.1186/s12894-024-01469-w
[9] Yamamoto K, Kuroda T, Kubota S, et al. Cushing's syndrome developing myasthenia gravis with takotsubo cardiomyopathy after adrenalectomy: a case report. BMC Neurol. 2024 Sep 20;24(1):355. doi: 10.1186/s12883-024-03866-y. DOI: https://doi.org/10.1186/s12883-024-03866-y
[10] Choudhary J, Prabhudesai A, Agarwal A. Anaesthetic Management of a Patient with Myasthenia Gravis for Laparascopic Cholecystectomy: A Case Report. | EBSCOhost [Internet]. Vol. 13. 2019 [cited 2025 Jun 25] DOI: https://doi.org/10.7860/JCDR/2019/42340.13156
[11] Varghese GM, Trowbridge P, Doherty T. Investigating and managing pyrexia of unknown origin in adults. BMJ. 2010;341:c5470. doi: 10.1136/bmj.c5470. DOI: https://doi.org/10.1136/bmj.c5470
[12] Abdelmaseeh TA, Azmat CE, Oliver TI. Postoperative Fever. [Updated 2023 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482299/
[13] Bhat A, Dean J, Aboussouan LS. Perioperative Management in Neuromuscular Diseases: A Narrative Review. J Clin Med. 2024 May 17;13(10):2963. doi: 10.3390/jcm13102963. DOI: https://doi.org/10.3390/jcm13102963
[14] Neuman A, Hendrix JM, Granlund B. Anesthesia for Patients with Myasthenia Gravis. [Updated 2025 Mar 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572091/
[15] Ferriere A, Tabarin A. Cushing's syndrome: Treatment and new therapeutic approaches. Best Pract Res Clin Endocrinol Metab. 2020 Mar;34(2):101381. doi: 10.1016/j.beem.2020.101381. DOI: https://doi.org/10.1016/j.beem.2020.101381
