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Background: With the COVID-19 vaccine now available, there have been occasional reports of post-vaccination neurological complications. Case presentation: In this report, we present a case of neuromyelitis optica spectrum disorder (NMOSD) that developed one month after the patient received the second dose of BIBP COVID-19 vaccine (SARS-CoV-2-Vaccine [Vero Cell] Inactivated). The patient presented with itching, numbness in the hand and right side of the face, as well as nausea, vomiting, and hiccups. Brain MRI revelead lesions in the area postrema, medulla, and bilateral hypothalamus, which are typical of NMOSD. Serum antibodies to anti-AQP4 and anti-MOG were negative. Conclusion(s): The pathogenesis of NMOSD development after vaccination is still unknown. NMOSD is generally aggressive and disabling, it is important for the neurologist to be attentive to the highly variable clinical presentation after COVID-19 vaccination for early diagnosis and effective treatment.Copyright © 2023
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Background: Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune, rare demyelinating disease of the central nervous system characterized by recurrent attacks which usually involve optic nerves and spinal cord. Although the most common symotoms are myelitis and optic neuritis, it can be presented as cerebral syndromes mainly those related to the brain stem and diencephalon. Since NMOSD is a rare disease and the epidemiological data on this disorder is still insufficient, the establishment of registry and long-term follow up studies are needed to assess the disease course and behavior over a period of time. Material(s) and Method(s): We stablished an electronic registry system for NMOSD patients in the MS center of Kashani hospital, Isfahan, Iran, since spring 2016. Every patient suspected for NMOSD and documented in our database was included in a follow up study to monitor their disease course and progression. Anti AQP4 antibody and Anti MOG antibody were checked for all patients in a unique lab by cell based assay method. Demographic data and clinical characteristics such as family history, comorbidities,education, number of relapses, presentation signs and radiological findings were recorded. Moreove, relapses, treatment change, triggers, and COVID-19 infection were documented. We investigated the effect of the COVID19 pandemic and vaccination on NMOSD patients. Result(s): This study included 173 cases with definite diagnosis of NMOSD, and 56 ones were seropositive for AQP4 Ab. 142 were females of which 46 were in the seropositive group. Their mean age was 40.02+/-11.11 years (45.78+/-12.88 in AQP4Ab positive group). The mean of age at disease onset was about 30.16+/-11.90 years. The mean time of follow up was 55.84+/-18.94 months until today. In 76 patients, there were LETM in the first cervical MRI. 123 patients revealedbabnormality in the first brain MRI. 27 patients had hypothyroidism as the most common comorbidity. 36 cases reported positive family history of multiple sclerosis and also 4 had a family history of NMOSD. Conclusion(s): The mean age of onset did not differ between seropositive and seronegative group but it was higher than MS patients. Brain MRI showed abnormality in NMOSD patients. Female/male was 4.4/1 which is lower than other studies.Copyright © 2022
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Background Vaccination is a recognised trigger of ADEM and approximately 50% paediatric cases have antibodies to MOG. The SARS-CoV-2 mass vaccination programme could therefore trigger cases of MOGAD. Neuromyelitis optica (NMO) is an autoimmune inflammatory condition of the CNS associ- ated with antibodies to AQP4. Method Ten patients (ages 22 - 65 years) with antibodies to MOG or AQP4 were referred to the NHS England NMO service having developed acute onset CNS inflammation within 8 weeks of vaccination. Results Eight patients had MOGAD, seven of whom received the AstraZeneca vaccine (AZV) and one the Pfizer vaccine (PV). Only the post-PV MOGAD patient presented with typical adult-onset phenotype of isolated ON. All post-AZV MOGAD patients presented atypically;85.7% had LETM and 71.4% had intrac- erebral lesions, resembling ADEM more commonly seen in paediatric MOGAD. The atypical presentation supports a causative role of AZV, but the role of PV is less convincing. Two patients had AQP4-NMOSD with typical demographic features. Both received AZV. Less typically, one young adult presented with LETM rather than characteristic young adult ON, the other had a silent short segment myelitis, which is rarely seen in AQP4-NMOSD. Both patients achieved good outcomes. Conclusion We discuss the potential causation and pathophysiological mechanisms.
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Background: Neurological autoimmune disorders are often triggered by bacterial and viral infections, with growing evidence supporting coronavirus disease 2019 (COVID-19) infection precipitation of these disorders. COVID-19 is already implicated in causing discrete para-infectious neurological syndromes: acute disseminated encephalomyelitis (ADEM), transverse myelitis, neuromyelitis optica spectrum disorders (NMOSD), Guillain-Barre syndrome (GBS), and is also associated with encephalopathy, acute cerebrovascular disease, neuromuscular disorders, and seizures. Case Presentation: We describe a case of a 43-year-old Asian woman with chronic Hepatitis B (HBV) co-infected acutely with COVID-19, presenting with urinary retention, bilateral blindness, thoracic sensory level, and quadriparesis. Extensive workup narrowed down her diagnosis as seronegative NMOSD. She had complete resolution of symptoms after treatment with concurrent plasma exchange (PLEX), high dose corticosteroids, and emtricitabine-tenofovir. Follow-up visit showed no seroconversion at 6 months and no relapses. Conclusion(s): Our literature review highlights the likely link between COVID-19 infection and the development of neurologic autoimmune diseases. Our literature review supports a virus-triggered immune-mediated process rather than neuro-invasion. Many viral illnesses have been linked to the development of NMOSD and anti-AQP4 antibody-related myelitis. Additionally, there is limited literature linking chronic HBV infection with the development of optic neuritis and speculation thatcross-reactivity between HBsAg and myelin antigens may lead to the development of demyelinating diseases in the CNS and PNS. We observed remarkable clinical improvement after treatment with alternating days of IV methylprednisolone and therapeutic PLEX.Copyright © 2022
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Background: Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune disease, targeting the central nervous system, rarely associated with vaccination. Case report: We report a case of a 47 year-old healthy woman who presented, ten days after the first dose of SARS-CoV-2 Vaccine AstraZeneca (Vaxzevria), with back pain, tetraplegia, urinary retention, dysarthria and dysphagia. The patient was diagnosed NMOSD. She underwent intravenous-corticosteroids, vein-Immunoglobulin and plasma-exchange without significant improvement . Conclusion(s): The absence of any possible related conditions, the temporal relation with anti-SARS-CoV-2 vaccination, suggest that, in our case, NMOSD may be due to the cross reaction from Vaxzevria.Copyright © 2021 The Author(s)
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Case Report: A 4-year-old African American male presented to an outside emergency department (ED) following sudden inability to move left upper extremity. Past medical history was unremarkable and routine vaccinations were up to date. Radiograph of affected extremity ruled out fractures and patient was discharged to follow up with primary care physician. Two days later mother brought him to our ED due to persistent left upper extremity paralysis, poor appetite, and subjective fever. On exam his left arm was warm and tender to dull and sharp touch;he had definite loss of active movement, hypotonia and absence of deep tendon reflexes. The patient had winging of left scapula and could not shrug left shoulder. MRI of cervical and thoracic spine showed enlargement of spinal cord from C2-C6 level with gray matter hyperintensity, slightly asymmetric to the left. Laboratory studies showed leukocytosis (14 000/mcL) and CSF studies showed pleocytosis of 89 WBC/mcL (93.3% mononuclear cells and 6.7% polymorphonuclear cells), 0 RBCs, normal glucose and protein, and a negative CSF meningoencephalitis multiplex PCR panel. Due to high suspicion of demyelinating or autoimmune condition he was treated with high dose steroids and IVIG. Subsequently neuromyelitis optica was ruled out as aquaporin-4 receptor antibodies (AB) and myelin oligodendrocyte glycoprotein AB were normal. CSF myelin basic protein and oligoclonal bands were absent ruling out demyelinating disorders. CSF arboviruses IgM and West Nile IgM were negative. He showed minimal improvement in left upper extremity movement but repeat spinal cord MRI one week later showed improved cord thickness with less hyperintensity. Respiratory multiplex PCR was negative including enteroviruses. Repeat CSF studies after IVIG showed increased IgG index and IgG synthesis suggestive of recent spinal cord infection, consistent with acute flaccid myelitis (AFM). Pre-IVIG blood PCR was invalid for enteroviruses due to PCR inhibitors found in the sample. Blood post-IVIG was negative for mycoplasma IgM, West Nile IgM, and arboviruses IgM. Enterovirus panel titers (post-IVIG) were positive for coxsackie A (1:32), coxsackie B type 4 (1:80) and 5 (1:320), echovirus type 11 (1:160) and 30 (1:80) as well as positive for poliovirus type 1 and 3. These titers could not distinguish acute infection from patient's immunity or false-positives as a result of IVIG. He was discharged with outpatient follow-up visits with neurology, infectious disease, occupational and physical therapy, showing only mild improvement after discharge. Discussion(s):With the anticipated resurgence of AFM after the peak of COVID-19 pandemic, our case illustrates the need to consider this diagnostic possibility in patients with flaccid paralysis. It is important to remember CSF IgG synthesis is not affected by IVIG. In addition when treatment plans include IVIG, appropriate samples should be collected before IVIG to facilitate accurate work-up for infectious diseases. Copyright © 2023 Southern Society for Clinical Investigation.
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Neuromyelitis optica spectrum disorders (NMOSD) is an immunemediated inflammatory disorder of the central nervous system. SARS-CoV-2 infections not only affect the lungs but generally all organs including the central nervous system. The underlying pathophysiology for SARS-CoV-2 associated CNS disease is suspected to be immunogenic. Therefore, the question is whether COVID-19 can trigger relapses in NMOSD patients. On the other hand, there have been reports that COVID-19 vaccination may trigger a relapse. The aim of our study was to assess the risk of NMOSD relpase after SARS-CoV-2 infection or after vaccination. Department of Neurology Medical University of Warsaw is a reference center for treatment of NMOSD patients in Poland. Nowadays we are taking care on seventy-five patients meeting NMOSD diagnostic criteria. As of March 31, 2022, we registered 47 SARS-CoV-2 infections. Twenty-two SARS-CoV-2 infections were reported in patients prior to COVID-19 vaccination (19 females, 3 males). Mean age of patients was 49+/-10 years, mean EDSS 4.5+/-1.5. Twenty (90.9%) patients were on immunosuppressive therapy (rituximab -11, steroids-4, inebilizumab -2, azathioprine -1, satralizumab -1, mycophenolate mofetil -1). Twenty-five SARS-CoV-2 infections occurred after the full course of vaccination (23 females, 2 males). Mean age of patients was 50+/-12 years, mean EDSS 3.6+/-1.7. Twenty-three (92%) patients were on immunosuppressive therapy (rituximab - 12, inebilizumab - 1, azathioprine - 3, satralizumab - 3, mycophenolate mofetil - 4). Three patients had a relapse after COVID-19 (within three months). Two of these people were still unvaccinated at the time. These patients were not receiving full immunosuppressive treatment at the time (one patient developed COVID-19 right after the first dose of rituximab, the other patient received the last dose of rituximab 18 months earlier). The third patient was treated with rituximab and was fully vaccinated. NMOSD relapse occurred in 6% of patients confirmed with COVID-19. Thee risk of relapse was even lower (2%) among patients properly treated with immunosuppressants. Of our seventy-five patients, only two were not vaccinated against SARS-CoV-2. All patients receivedmRNA SARS-CoV-2 vaccines. No vaccine-related NMOSD attack has been reported. Conclusion(s): Patients with NMOSD treated with immunosuppressants have a low risk of a relapse due to COVID-19 infection. In our study mRNA COVID-19 vaccines do not increase the risk of a relapse.
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Background: Viral infections are thought proposed as a possible cause of central nervous system (CNS) demyelinating diseases, including multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). During the past two years, CNS demyelinating events associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported, but causality is unclear. Objective(s): To investigate the relationship between CNS demyelinating disease development with antecedent and/or concurrent COVID-19 infection. Method(s): A systematic literature review of all publications describing either a new disease onset or relapse of CNS demyelinating diseases (MS, NMOSD, MOGAD) in association with SARS-CoV-2 infection was performed utilizing PRISMA guidelines. Descriptive statistics were used for data analysis, using a case analysis approach. Result(s): Fifty articles were meet inclusion criteria for the study. Most of the reported cases ofNMOSD (n=10., 66.7% of reported cases)and MOGAD (n=12, 92% of reported cases) were of new disease onset, presenting with typical clinical and radiographic features of these conditions, respectively. In contrast, reported MS cases varied amongst newly diagnosed cases (n=11, 13% of reported cases), relapses (n=48, 56.5%) and pseudo-relapses (n=26, 30.5%). Median duration between COVID-19 infection and demyelinating event onset was 9 days (range 0-30 days) in NMOSD, 4 days (range-7-+21 days) in MOGAD, and 13.5 days (range-21-+180 days) in MS. Most cases received high-dose corticosteroids with a good clinical outcome. Conclusion(s): Based upon available literature, the rate of CNS demyelinating events occurring in the setting of preceding or concurrent SARS-CoV-2 infection is relatively low given the prevalence of infection. The clinical outcome of new-onset or relapsing MS, NMOSD or MOGAD associated with antecedent or concurrent infection is mostly favorable. Larger prospective epidemiological studies are needed to better delineate the impact of COVID-19 on CNS demyelinating diseases.
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Background: A severe antibody-mediated inflammatory demyelinating disease of the central nervous system is neuromyelitis optica spectrum disorder (NMOSD). Azathioprine (AZA) and Rituximab (RTX) were used to treat NMO-SD patients though not FDA approved yet. Aim of the study: To compare the effectiveness and safety of rituximab treatment versus azathioprine in treating individuals with NMOSDs. Methods: Seventy four Egyptian individuals with NMOSDs in this retrospective observational study and collecting their medical records from multiple sclerosis (MS) clinics, Neurology Departments, El-Maadi Military Hospital, and Cairo University hospitals. Fourty four patients received either treatment over two year duration, Group 1 (rituximab group) consisted of 19 patients, while group 2 (azathioprine group) consisted of 25 patients. Their full medical history, general and neurological examination, MRI brain and spinal cord results, and laboratory investigation were collected including immune assays and AQP-4 antibody. Results: There was no statistically significant difference between the groups in terms of brain MRI data at the baseline and outcomes. Between the two groups, there were statistically significant differences in last observer spinal MRI (p=0.025), annual relapse rate before treatment with RTX group (P=0.021), EDSS pretreatment (p=0.005), annual relapse rate post-treatment. When it came to the number of relapses after treatment, there was a high statistically significant difference between the two groups (p=0.016), with group 1 (RTX group) having zero relapses. There was a statistically significant decrease comparing EDDS scores pre-and post-treatment regarding the RTX group (p=0.003). Adverse events were Infusion rate reaction (5.3%) and pneumonic COVID (9.5%) of patients. Conclusion: RTX is more helpful and less harmful for NMO-SD patients than AZA.
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Background: Coronavirus 2019 (COVID19) is a new coronavirus which has created a pandemic since early 2020. Neuromyelitis Optica Spectrum Disorder (NMOSD) patients are more affected by psychological effects of COVID19 pandemic such as anxiety and fear because they may be worried about being infected by COVID19 (due to the nature of disease and treatment by immunosuppressant drugs) and also they are concerned about their treatment protocol and disease relapses during the pandemic. Material(s) and Method(s): The aim of study was to evaluate the anxiety due to COVID19 infection, 3 and 12 months after beginning of epidemic in Iran.The study was performed in patients of NMOSD Cohort Clinic of Kashani hospital, Isfahan. We first asked individuals if they were anxious or afraid of the pandemic subjectively. To investigate the objective level of anxiety, Hospital Anxiety and Depression Scale (HADS-A) questionnaire was filled. Moreover, we asked them about respecting general cautions and sanitary protocols to prevent COVID19 infection. Result(s): Study included 120 patients (96 female) with mean age of 36.37±9.69 and mean duration of disease about 8.49±5.35 years. A total of 96 cases (80%) experienced anxiety during the first 3 months of pandemic. The point is that their level of anxiety decreased significantly with the prolongation of pandemic after 9 months and just 66 patients (55%) showed anxiety subjectively on the second survey. Based on HADS-A score, 92 patients (76.66%) were anxious on the third month while after one year of epidemic 70 cases (58.33%) showed anxiety. Respecting preventive measures increased in the same period. Conclusion(s): Along with the COVID19 pandemic prolongation, the level of anxiety had decreased gradually while the level of alertness and attention was almost high. It should be considered that this awareness must be preserved till the end of pandemic.
ABSTRACT
Various effective monoclonal antibodies (mAbs) have been approved for both multiple sclerosis (MS) and anti-aquaporin-4-seropositive neuromyelitis optica spectrum disorders worldwide, including in Japan. As these newer mAbs have distinct modes of action that effectively suppress the recurrence of inflammation and slow disability progression, they can modulate and interfere with the protective immune response against pathogens, resulting in various infectious complications. Among various mAbs, natalizumab (NTZ) has the highest risk of causing progressive multifocal leukoencephalopathy (PML), a rare but fatal opportunistic brain infection caused by John Cunningham polyomavirus. Switching from NTZ to B-cell-depleting mAbs, such as ocrelizumab, is also a possible risk factor for PML development. Alemtuzumab carries the risk of reactivation of varicella-zoster virus (VZV);therefore, prophylactic acyclovir treatment is required. NTZ has also been associated with VZV reactivation. Eculizumab can cause severe meningococcal infection due to Neisseria meningitis, and vaccination prior to treatment induction is required. Attention to the reactivation of hepatitis B or Mycobacterium tuberculosis is also needed during mAb therapy. Additionally, in the era of severe acute respiratory syndrome coronavirus 2 infection (COVID-19), the risk for of developing severe COVID-19 may be associated with some mAbs, such as B-cell-depleting agents. Thorough understanding and mitigation strategies for infectious risks are essential.
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Coronavirus disease 2019 (COVID‑19) caused by 2019 novel coronavirus (2019‑nCoV), has constituted a major worldwide public health event. At present, vaccination against COVID‑19 is being actively promoted in order to establish a population immune barrier. Here consensus guidance is given on the safety and efficacy of COVID‑19 vaccination in patients with multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD). Overall, the risk of 2019‑nCoV infection in MS or NMOSD patients is not increased than that in the general population. The existing vaccines against COVID‑19 do not cause vaccine‑derived infection in patients receiving any immune interventions, although the effectiveness of vaccine may be reduced in some cases (such as the use of sphingosine‑1‑phosphate receptor modulator or B‑cell depletion agent). There is no sufficient evidence that vaccination will aggravate MS or NMOSD, or directly lead to disease recurrence. Therefore, after fully informed consent and pre‑assessment of vaccination‑related risk, it should be recommended that MS and NMOSD patients with stable disease control be vaccinated against COVID‑19.
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Objective: To determine the optimal time for SARS-CoV-2 mRNA vaccination, after infusion with anti-CD20 therapy, in patients with multiple sclerosis and neuromyelitis optica spectrum disorder (MS/NMOSD) as there are currently no guidelines. Background: To achieve adequate immunity against SARS-CoV-2, mRNA vaccines (BNT162b2 or mRNA-1273) stimulate B and T cells. Therefore, it is imperative to ensure MS/NMOSD patients on anti-CD20 therapy have enough B cells to produce antibodies at the time of vaccination. Design/Methods: This was a retrospective study at Rutgers New Jersey Medical School, Newark. We identified all MS/NMOSD patients on anti-CD20 therapy (Ocrelizumab or Rituximab) who received a SARS-CoV-2 mRNA vaccine. Some of these patients were not on the standard, biannual dosing schedule due to treatment guideline modifications made during the pandemic. Antibody response to the SARS-CoV-2 spike protein was checked at least 4 weeks after the second dose of the vaccine. Results: We analyzed 23 vaccinated MS/NMOSD patients on anti-CD20 therapy (87% on Ocrelizumab and 13% on Rituximab). Patients were divided into two groups: those who developed antibodies after vaccination (52%) and those who did not (48%). There was no significant difference between the two groups in age, gender, MS type, expanded disability status scale, type of anti-CD20 therapy, and brand of vaccine. However, there was statistical significance in the interval between infusion and vaccination between the groups (p-value -0.03;9.2±3.9 vs 6.2±3.1months). Additionally, none of these patients had a relapse. Conclusions: The mean interval between infusion and vaccination was 9.2 months in those that developed antibodies and 6.2 months in those that did not. Patients on anti-CD20 therapy may mount an immune response when vaccinated if the time between infusion and vaccination is extended beyond 6 months. The main limitation of this study was the variable timing in the collection of CD19 counts.
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Objective: To assess symptoms, severity, outcome of Covid 9 in Multiple sclerosis patients ( including NeuroMyelitis Optica )and to assess the prognostic factors for severe Covid19 Background: Covid 19 pandemic came with its own challenges of novelty, lack of information uncertainty of treatment and its effect on chronic autoimmune diseases like Multiple sclerosis. The outcome of covid 19 with immunosuppressive and immunomodulatory treatment in multiple sclerosis was not known till this year. We share our observation of multiple sclerosis patients including neuromyelitis optics who contracted Covid 19 in Dubai UAE, during April 2020 to Sep 2021 in 2 major hospitals treating multiple sclerosis. Design/Methods: All Multiple sclerosis Patients following in Rashid hospital and Alzahra Hospital Neurology apartment who had Covid 19 were included in this observational study. Results: 55 MS patient with Covid 19 ( including 2 NMO) were studied. Age of the patients ranged from 19 to 58years. There were 39 females and 16 males. 43 were RRMS, 6 -SPMS,4- CIS, 1- PPMS and 2 NMOSD. 6 were on interferons, 2 on teriflunamide, 8 on dimethylfumarate, 12 on fingolimod, 3 on natalizumab, 1 on alemtuzumab, 1 on rituximab, 9 on cladribine, 12 on ocrelizumab and 1 on azathioprine. 47 had fever, 30 anosmia, 28 had fatigue and 42 had sorethroat and cough, 5/55 had pneumonia.39/55 had mild covid, 13/55 had moderate and 3 had severe covid 19. 3/55 needed ICU. There were 2 deaths, first with MS, EDSS 6.5 on ocrelizumab and second with NMO (EDSS 7.0)on rituximab Conclusions: The disease course and outcomes were mostly favorable with most patients not requiring hospitalization. A higher EDSS score, progressive disease, use of rituximab, and ocrelizumab(antiCD20 therapy) were associated with the mortality encountered. Age, sex, smoking history, and duration of MS were not independent risk factors for increased severity or adverse COVID-19 disease outcomes.
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Objective: To describe, to the best of our knowledge, the first case of myelin oligodendrocyte glycoprotein (MOG) antibody syndrome associated with the Moderna COVID-19 mRNA vaccine, and a case of acute transverse myelitis (ATM) associated with the Pfizer COVID-19 mRNA vaccine. Background: Post-vaccination CNS demyelinating syndromes have been reported with different vaccines, most notably the influenza and human papilloma vaccines. Two cases of new-onset multiple sclerosis (MS) and a case of new-onset neuromyelitis optica (NMO) associated with the Pfizer vaccine have been reported. One case of new-onset relapsing-remitting MS was reported after the Moderna vaccine. Design/Methods: NA Results: A 38-year-old man developed left blurry vision, lower extremity weakness/paresthesia and bowel/bladder dysfunction three days after receiving the Moderna vaccine. He was diagnosed with left optic neuritis and longitudinally extensive transverse myelitis;he tested positive for MOG antibody. A 39-year-old woman presented with progressive lower extremity weakness/numbness seven days after receiving the Pfizer vaccine. She was diagnosed with ATM. Both patients improved with intravenous corticosteroids. Conclusions: The association between CNS demyelinating syndromes and vaccination has been reported for many years. The proposed pathogenesis of CNS demyelinating syndromes after vaccines includes molecular mimicry, epitope spreading, bystander activation, polyclonal activation, effects of adjuvants, and depends on vaccine-related factors like type, dose, and route of administration. The adjuvanticity of COVID-19 vaccines is novel in that it involves Toll-like Receptor (TLR) 7 and 9 agonism, and several immune-mediated disorders have been linked to altered nucleic acid metabolism and processing that have stimulated TLR-7 and TLR-9 experimentally. While the risk of CNS demyelinating events is non-negligible, the incidence is very low. The rate of demyelinating events after the COVID-19 infection is higher. Therefore, we feel that the overall benefits of vaccination outweigh the marginal risk. However, providers should be aware of this potential neurological complication of the COVID-19 mRNA vaccines.
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Objective: To report a case of antibody-positive neuromyelitis optica (NMO) after COVID-19 vaccination. Background: Neuromyelitis optica spectrum disorder is a rare demyelinating disorder of the central nervous system characterized by longitudinally extensive transverse myelitis (LETM) and severe, sometimes bilateral optic neuritis. The majority of cases have serologic or CSF antibody for aquaporin-4 (AQP4). Design/Methods: Case report Results: A 19 year old woman with no prior medical history presented with two days of progressive, severe weakness and sensory changes first in the arms, then legs. On the morning of presentation, she woke with urinary incontinence. She had received COVID-19 vaccination (Moderna) fifteen days preceding her onset of symptoms. Examination revealed sinus tachycardia, MRC grade 3-4/5 power in the arms, 0/5 in the legs with approximately T4 sensory level. Cervical spine MRI revealed T2 prolongation in the spinal cord extending from the cervicomedullary junction to the conus medullaris. CSF revealed neutrophilic pleocytosis with increased IgG synthesis rate and positive CSF AQP4 antibody;serum AQP4 and MOG antibodies were negative. Bilateral, saddle pulmonary emboli were discovered shortly after admission. Her NMO was treated with high-dose intravenous methylprednisolone, plasmapheresis, and rituximab. Conclusions: This case describes a severe, new presentation of antibody-positive neuromyelitis optica following vaccination against COVID-19.
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Objective: To describe cases of transverse myelitis (TM) associated with mild COVID-19 in adults. Background: Post-infectious TM is described after various infections but is not as well-known after COVID-19. Design/Methods: We present a series of 2 cases who developed TM after infection with SARS-CoV-2. Case 1: 55-year-old male with coronary artery disease presented with worsening paraparesis over 4 months, T4 sensory level and urinary retention, starting two weeks after mild COVID-19 illness. MRI showed T2 hyperintensity extending from the lower medulla to T3 spinal cord. CSF analysis revealed elevated protein and pleocytosis. His functional status improved after plasma exchange. Subsequently, his symptoms worsened and was treated with multiple courses of glucocorticoids. He recently started Rituximab and continues to have leg weakness with urinary retention. Case 2: 66-year-old male with diabetes mellitus presented in a wheelchair with rapidly progressive paraparesis over 10 days, starting six weeks after mild COVID-19 illness. He was initially diagnosed with GBS and received IVIG with no improvement. MRI revealed T2 hyperintensity in the lateral corticospinal tracts of cervical and thoracic spinal cord. Somatosensory evoked potential testing showed mild bilateral demyelinating lesions involving the dorsal columns between the C6-parietal cortex. CSF analysis was normal. Plasma exchange therapy provided minimal improvement. He remains wheelchair bound with urinary urgency. In both cases, other causes of TM including neuromyelitis optica, myelin oligodendrocyte associated disease, neurosarcoidosis and paraneoplastic myelopathy were ruled out. Conclusions: SARS-CoV2 may cause a post-infectious TM. While causation remains difficult to prove, our cases suggest TM was precipitated by COVID-19 given the temporal association and no other identified etiology. Our cases continued to have significant neurologic deficits likely due to delayed diagnosis. These cases add to the growing body of evidence of neurologic complications associated with COVID-19. Further studies are needed to establish the incidence and outcomes of post-infectious TM after COVID-19.
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Three new drugs, all based on messenger RNA or small interfering RNA technology, represented a major therapeutic advance in 2021. But the bigger picture is that most of the new authorisations that advanced patient care were adaptations of existing drugs. And that more than half of this year's new authorisations were not advances, and in fact about one-tenth represented a step backwards compared to existing options.