“When HIV meets MG: Is immune reconstitution in the mix?”

• Concurrent autoimmune disorders with HIV are rare, and the diagnosis is often delayed, especially concerning neuromuscular disorders • Autoimmune myasthenia gravis may be seen in patients with neuromuscular immune reconstitution syndromes • Rituximab may be an effective treatment for immune reconstitution syndromes in HIV positive patients Autoimmune disorders and human immunodeficiency virus (HIV) positivity rarely coexist. We report a case of anti-muscle-specific kinase (MuSK) antibody-positive myasthenia gravis (MuSK+ MG) in an HIV positive patient. Antiretroviral therapy resulted in an immune reconstitution syndrome, resulting in worsening of MG symptoms. However, the role of additional immunomodulation in this setting has yet to be clarified. A 44-year-old woman with virologically suppressed HIV infection presented with fluctuating oculobulbar symptoms, limb weakness, and respiratory failure. These symptoms were noticed around 6 months following antiretroviral therapy (ART) modification. Electrophysiological studies and elevated anti-MuSK antibody levels confirmed MuSK + MG. An increase in the CD4 count from 115 to 681 cells/µL following the ART modification was consistent with immune reconstitution. Treatment with corticosteroids, Rituximab, and opportunistic infection prophylaxis resulted in a reduction in her MG symptoms with no adverse side effects. This case underscores the complexities of managing autoimmune diseases in HIV, where ART-induced immune reconstitution may unmask or trigger autoimmunity. Early diagnosis and targeted therapies can improve outcomes. In this case, Rituximab initiation facilitated symptom control and steroid tapering. The need for a multidisciplinary approach to balance immunosuppression and infection risks has been emphasized.