Background: Myasthenia gravis (MG) is autoimunne disease caused by production of antibodies against acetylcholine receptors resulting in skeletal muscle weakness. It can be rearly associated with other autoimmune diseases like Systemic lupus erythematosus (SLE).  Myastenia gravis presented as isolated respiratory failure as the first sign of the disease is very rare. 
Case report: We present a case of a 22 years old caucasian women with previosly diagnosed SLE who was admitted in our ICU from another hospital because of acute respiratory failure. The woman delivered her baby with cesarean section under general anaesthesia eight days before. After prolonged aweakening period she was extubated but in the next days she developed muscle weakeness which led  to respiratory insufficiency.  She wasn't taking any medication for SLE during her pregnancy. She was transported in our ICU after she was intubated. On the admition she was GCS 15, intubated, on the CPAP mode of ventilation, with no evidence of upper and lower extremities weakness. The chest computed tomography (CT) scan showed no evidence of pulmonary thromboembolism or thymic hyperplasia and thymoma. Prostigmin test was positive so therapy with pyridostigmine bromide, prednisone and  plasmaferesis  started.  The anti–acetylcholine receptor (AChR) antibody came back elevated. After 2nd plasmaferesis she was breathing sufficiently so she was extubated.  She was dissmised full recovered. 
Discussion: Myasthenia gravis (MG) and Sistemic lupus erythematosus (SLE) are both autoimmune diseases with different cause and course of the disease but they can preceed or coexist. This coexistence may cause more severe myastenic course compared to MG alone. Acute respiratory failure usually develops in late stage of the disease. However, in some patients respiratory failure is the initial presenting symptom.  


10 / Acute respiratory failure after cesarean section in patient with SLE due to myasthenia gravis