A Case of Sars-Cov-2 Omicron Variant Associated Acute Encephalomyelitis

With the ongoing pandemic of SARS-CoV-2 many neurological complications in relation to COVID-19 infection as well as immune-mediated and vaccine-associated phenomena have been described. To our knowledge, there has been no publication of a case of SARS-CoV-2 Omicron variant associated acute encephalomyelitis. We present a case of a 73-year-old woman with no relevant Background history who is otherwise fit and well and fully vaccinated. She suffered from mild COVID symptoms and had a positive PCR test with presumptive Omicron variant on day 2. Five days into her respiratory illness she developed in quick suc- cession sensory disturbances of hands and feet, bilateral asymmetric flaccid leg weakness, and mild arm weakness. She had absent deep tendon reflexes in the legs and diminished deep tendon reflexes in the right arm. MRI of brain and spine showed signal changes in the brainstem, cervical and low thoracic cord in keeping with acute encephalomyelitis. Her CSF showed an inflammatory picture with raised protein of 1.27g/L and no cells. At the time of submission, the patient received treatment with five days of intravenous steroids followed by ongoing plasma exchange and no comment on treatment response can be made at this stage.

Two Cases of Neurological Complications After mRNA Vaccination for COVID-19

Objective: We present two patients with neurological complications following COVID-19 mRNA vaccination. Background: Post-vaccinal myelitis and demyelination is well described. We investigated two patients presenting inflammatory demyelination following mRNA based vaccination against COVID-19. Design/Methods: Patients were referred to the treating neurologist for a second opinion as possible cases of multiple sclerosis. Clinical neurological evaluation, MRI imaging of brain and spine as well as serum and cerebrospinal fluid (CSF) analysis was performed. Results: In case 1, the patient developed left-side numbness and difficulty walking six weeks post-second dose of the Moderna mRNA COVID-19 vaccine. She was found to have an enhancing thoracic cord lesion on MRIs, and CSF ELISA studies showed highly elevated IgG levels against the spike protein receptor-binding domain (S1-RBD) of COVID 19. In case 2, the patient began to hiccup and vomit, developed diplopia, and right-side weakness and numbness around two days post-second dose of the Moderna vaccine. MRIs showed two lesions on her brain and a C4 enhancing lesion on her spinal cord. CSF showed oligoclonal bands. However, further analysis of her spinal fluid showed highly elevated IgG antibodies to the S1-RBD. Conclusions: Initially, case 1 was diagnosed with transverse myelitis and possible multiple sclerosis, and case 2 with multiple sclerosis. Both patients likely would have received long-term immunosuppressive therapy had vaccine complications not been suspected. The presence of CSF antibodies to the S1-RBD protein suggests an immune response to the mRNA COVID-19 vaccinations crossing over to the CNS as the likely cause of these neurological complications. In patients developing acute neurological complaints in the period following vaccination, even with the presence of oligoclonal bands, CSF should be analyzed for reactivity against the S1-RBD. Further investigation is required to explain the mechanism of this response and subsequent complications. Both patients are clinically improving and will continue to be managed by a neurologist.

Combined central and peripheral demyelination syndrome after COVID-19 vaccination with brisk response to plasma exchange and steroids

Objective: - Report a case of combined central and peripheral combined demyelination (CCPD) syndrome after COVID19 vaccine with brick improvement to steroids and PLEX - Provide a brief literature review of CCPD etiology and management Background: Combined central and peripheral demyelination (CCPD) is a rare, immunemediated disorder that presents with concurrent demyelination in the central and peripheral nervous system. Known clinical course and radiologic/electrodiagnostic features stem only from a limited number of case reports and small case series. The disease course can be monophasic or chronic. Response to immunomodulatory treatment is variable. Design/Methods: N/A Results: 59-year-old female presented with progressive lower extremity pain, weakness and urinary incontinence four weeks after receiving her second COVID-19 vaccine. Exam was notable for mild somnolence, restricted lateral gaze, right eye red desaturation without APD, ocular ataxia, left lower facial weakness, and lower extremity paresis with decreased reflexes. MRI of the brain and spinal cord showed multifocal supratentorial, intratentorial, cervical and thoracic cord white matter signal abnormalities with trace enhancement in combination with marked cauda equina enhancement. CSF showed albuminocytologic dissociation (protein of 184 and 2 nucleated cells). NMO, Anti-MOG and neurofascin-155 antibodies were negative. Electromyelogram and nerve conduction studies were consistent with a demyelinating polyneuropathy. The patient was treated with a 1 gram IV methylprednisolone daily and five treatments of plasma exchange. At six months, the patient had nearly returned to her previous baseline. Conclusions: CCPD is a rare inflammatory neurologic condition of peripheral and central demyelination. The etiology remains unclear, though viral infections and immunizations have been reported to proceed CCPD in some patients. Limited data is available to guide treatment but PLEX, IVIG and steroids are the most common. Outcomes are heterogeneous and methods to predict long term course remains uncertain. To our knowledge, this is the first reported case of CCPD after the COVID 19 vaccine.

Transverse Myelitis associated with COVID-19 in adults

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.

Case Series of New-Onset CNS Immunological Disorders Temporally Associated with mRNAbased COVID-19 Vaccines

Objective: To present a single-health system retrospective analysis of post-mRNA-based COVID-19 vaccination CNS autoimmunity conducted in the greater New York City area. Background: There have been rare reports associating mRNA-based COVID-19 vaccines with central nervous system (CNS) inflammation. We report a case series of five patients with newonset neurological disorders of immunological origin temporally associated with these vaccines. Design/Methods: Case-series. Results: Five cases of post-vaccination CNS disorders of immune origin were observed within two weeks of inoculation with either the first or second dose of mRNA-based COVID-19 vaccines (Moderna = 3, Pfizer = 2). This includes: Fatal ADEM (n = 1), new-onset NMO (n = 2), new-onset fulminant MS (n = 1), and meningoencephalitis (n = 1). The age of our patients ranged from 27 to 81, and three were female. None of the patients had pre-existing neurological illnesses and one had a pre-existing autoimmune condition (immune thrombocytopenia purpura). New-onset focal neurological symptoms were present in all five patients, including quadriparesis, numbness, diplopia, and encephalopathy. CSF pleocytosis was present in all patients, and three had elevated protein. All but one patient (meningoencephalitis) had contrastenhancing lesions involving either the cerebrum or spinal cord. Both NMO patients had longitudinally extensive transverse lesions involving the central thoracic cord. Aquaporin-4 serum antibody was present in one NMO patients and aquaporin-4 CSF antibody present in the other. All but one patient (fatal ADEM) clinically improved with pulse steroids or plasmapheresis. Conclusions: These are among the emerging cases of CNS immunological events temporally associated with mRNA-based COVID-19 vaccines. These findings should be interpreted with great caution as they neither prove a link nor imply a potential long-term increased risk in postvaccination CNS autoimmunity. Larger prospective studies are needed. The mRNA-based SARS-CoV-2 vaccines should continue to be strongly encouraged given their high efficacy in overcoming this pandemic.

Acute Disseminated Encephalomyelitis Secondary to Rubeola Infection Masquerading as New Onset Multiple Sclerosis in an Elderly Woman: Case Report

Introduction: Following an alarming surge of measles cases from declining immunization rates, it is important that clinicians recognize measles as a possible cause of otherwise unexplained symptoms, especially in patients with uncertain immunological status. Case: Over a 4-month period, a 76-year-old woman with a history of treated breast cancer experienced rapidly progressive and fluctuating focal weakness and numbness primarily affecting her lower extremities. Initially complaining of vague gastrointestinal symptoms upon returning from an extended stay in Florida, she was found to have active demyelinating lesions of her brain, cervical, and thoracic cord on MRI. This was initially thought to be new onset multiple sclerosis. CSF analysis showed critically high protein and, upon repeat analysis, positive rubeola and herpes IgM, which were elevated despite high dose steroid infusions and a steroid taper. Alternative diagnoses were ruled out, including: other infectious etiologies;endocrine/metabolic disorders;drug toxicity;malignancy;paraneoplastic disorders;transverse myelitis;multifocal cord infarction;stroke;seizure;and others. Repeat images displayed improvement of lesions and the patient was discharged to acute rehab with close neurological follow-up without steroids. Discussion: Acute disseminated encephalomyelitis is more likely in children, though cases are rare. This case of disseminated measles underscores the critical need for continued vaccination of at-risk populations, especially in those who are elderly or immunocompromised. Previous titers for immunity were not known, a potential limitation. Recent evidence demonstrates measles' ability to cause immune system "amnesia," potentially explaining this patient's concomitant herpes. As COVID-19 cases continue to present, recent evidence has linked the protective effect of the MMR vaccine against COVID-19's spread and severity. Conclusion: It is imperative that measles and other severe, preventable diseases continue to be closely monitored. Clinicians should assess benefits of proactively measuring rubeola titers in patients of all ages or in those who have previously received extensive immunosuppressive therapy.