1. Abstract 1.1. Background: There has been growing evidence of COVID-19 potentially causing a wide range of neurological abnormalities from as mild as anosmia to as serious as stroke. It is important to recognize that amid this pandemic, we have been seeing different manifestations and associations of COVID-19. 1.2. Case presentation: We present a case of a 45 years old female who presented with one day history of pain around the trunk followed by paresis in both lower limbs and urinary retention. MRI revealed features suggestive of transverse myelitis. No probable cause of transverse myelitis was found after extensive workup. Patient was incidentally found to be having COVID-19 PCR positive as a pre-requisite for the procedure of plasmapheresis. 1.3. Conclusion: We concluded that COVID-19 might be the cause of transverse myelitis in this patient. The patient was successfully treated with plasmapheresis. This case drives us at the conclusion that COVID-19 must be suspected in patients presenting with transverse myelitis.
Keywords: Transverse myelitis; COVID-19; Plasmapheresis; MRI; Spinal cord
2. Background COVID-19 has claimed innumerable lives globally. Apart from causing respiratory symptoms, this disease has been associated with many dreaded extrapulmonary manifestations; cardiac, gastrointestinal and neurological. We have a case of middle-aged female who presented with transverse myelitis and was incidentally found to be COVID-19 positive. Transverse myelitis is a heterogeneous syndrome characterized by acute or subacute spinal cord dysfunction resulting in paresis, a sensory level and autonomic (bladder, bowel, sexual) impairment below the level of lesion. Here we present a case of middle-aged female with no established premorbids experiencing transverse myelitis associated with COVID-19.
3. Case Presentation A 45 years old female with no established premorbid conditions, presented with one day history of circumferential tightness around her abdomen which gradually caused pain and radiated to both her thighs and legs. This was followed by weakness in both of her lower limbs and urinary retention. The weakness progressed within eight to ten hours. There was no history of fever, respiratory or gastrointestinal symptoms, any antecedent infection, vision changes or altered sensorium. On examination she was vitally stable with a blood pressure of 110/75 mmHg, pulse 74/min regular, RR 16/min. Neurological examination revealed 1/5 power in both lower limbs proximally and distally, along with spasticity and brisk ankle and knee reflexes. Planters were bilaterally upgoing. Sensory examination revealed decreased sensations below T10 (umbilical region). Rest of her systemic examination and fundoscopy was normal. Her lab tests including complete blood picture, liver function tests, electrolytes and renal function tests were normal. Chest Xray and electrocardiogram was normal. MRI brain did not show any evi A 45 years old female with no established premorbid conditions, presented with one day history of circumferential tightness around her abdomen which gradually caused pain and radiated to both her thighs and legs. This was followed by weakness in both of her lower limbs and urinary retention. The weakness progressed within eight to ten hours. There was no history of fever, respiratory or gastrointestinal symptoms, any antecedent infection, vision changes or altered sensorium. On examination she was vitally stable with a blood pressure of 110/75 mmHg, pulse 74/min regular, RR 16/min. Neurological examination revealed 1/5 power in both lower limbs proximally and distally, along with spasticity and brisk ankle and knee reflexes. Planters were bilaterally upgoing. Sensory examination revealed decreased sensations below T10 (umbilical region). Rest of her systemic examination and fundoscopy was normal. Her lab tests including complete blood picture, liver function tests, electrolytes and renal function tests were normal. Chest Xray and electrocardiogram was normal. MRI brain did not show any evi dence of demyelinating disease or space occupying lesion. MRI dorsal spine with contrast showed an abnormal long segment signal in thoracic cord extending from C7-T1 through T12 with similar patchy signal in conus medullaris and mild cord expansion and enhancement from T5 till T9 segment (Figure 1 and 2).
4. Discussion Patient was finally diagnosed as COVID related transverse myelitis. Two rare entities present in our patient were multi-level spinal cord involvement and improvement with plasmapheresis and not with intravenous steroids. Transverse myelitis is a heterogenous neurological disease in which there is inflammation of spinal cord usually involving the whole cross section of spinal cord. It is characterized by acute or subacute spinal cord dysfunction causing weakness and numbness of limbs, sensory and motor deficit, and autonomic dysfunction (sexual, bowel and bladder). Its etiologies are acquired demyelinating disorders (multiple sclerosis, neuromyelitis optica, ADEM), systemic inflammatory autoimmune disorders, para-infectious (viral; HIV, HSV, EBV, CMV, VZV, bacterial, fungal and even parasitic), para-neoplastic, drugs and toxins induced and atopy. Pandemic of COVID-19 emerged from Wuhan city of China in December 2019 and thereby spread throughout the world within a span of few months. It has claimed many lives, and also has caused significant morbidity in patients who develop ischemic stroke or who remain on domiciliary oxygen despite resolution of initial disease. Exact pathogenesis of acute transverse myelitis secondary to COVID-19 is unknown. Interleukin-6 is also involved in organ damage by causing endothelial damage, activation of complement and coagulation cascade [2, 3]. Cytokine storm is also a pathogenic cause in transverse myelitis [2, 3]. SARS-COV-2 has emerged as a fearful pandemic throughout the world engulfing many lives.
5. Conclusion There are only a few case reports of transverse myelitis associated with COVID-19. However, keeping in mind that we are still learning about how differently this virus affects every organ system, one should keep COVID-19 as a differential and a suspected cause of causing transverse myelitis.
References 1. Chow CCN, Magnussen J, IP J, Su Y. Acute transverse myelitis in covid-19 infection. BMJ Case Rep. 2020; 13(8). e236720.
2. Chakraborty U, Chandra A, Ray AK, Biswas P. COVID-19–associated acute transverse myelitis: a rare entity. BMJ Case Rep. 2020; 13(8).
3. Baghbanian SM, Namazi F. Post COVID-19 longitudinally extensive transverse myelitis (LETM)–a case report. Acta Neurol Belg. 2020; 18; 1-2.
4. Durrani M. Infectious Acute Transverse Myelitis Secondary to COVID-19, REBEL EM blog, August 27, 2020.
5. AlKetbi R, AlNuaimi D, AlMulla M, AlTalai N, Samir M, Kumar N, et al. Acute myelitis as a neurological complication of Covid-19: A case report and MRI findings. Radiol Case Rep. 2020; 15(9): 1591- 1595.
6. Munz M, Wessendorf S, Koretsis G, Tewald F, Baegi R, Krämer S, et al. Acute transverse myelitis after COVID-19 pneumonia. J Neurol. 2020; 267(8): 2196-2197.
7. Zachariadis A, Tulbu A, Strambo D, Dumoulin A, Virgilio GD. Transverse myelitis related to COVID-19 infection. J Neurol. 2020; 1-3.
8. Ahmad I, Rathore FA. Neurological manifestations and complications of COVID-19: A literature review. J Clin Neurosci. 2020; 77: 8-12.
9. Needham EJ, Chou SHY, Coles AJ, Menon DK. Neurological Implications of COVID-19 Infections. Neurocrit Care. 2020. 32(3): 667-671.
Anum Ashfaq. Transverse Myelitis in a Patient with COVID-19: A Case Report. Annals of Clinical and Medical Case Reports 2021