Total cervicothoracic myelitis in a patient with severe COVID-19 pneumonia

ABSTRACT

Background and aims: Patients with COVID-19 infection may have neurological complications, some of which can be rapidly progressing, requiring urgent intervention. Methods: Case report of acute myelitis in a COVID-19 patient. Results: A 49-year-old man, previously diagnosed with SARS-Cov2-infection, was admitted into the emergency department (ED) with a 3-day history of severe ascending bilateral weakness. On day five of his COVID-19 symptoms, he developed low back pain, lower limb paresthesia, and bilateral lower limb weakness, which progressed to severe quadriparesis with urinary retention over the next two days. There was no history of trauma, fever, preceding diarrhoea, or recent vaccination. Preliminary evaluation in the ED revealed respiratory failure with an increasing requirement for respiratory support. On neurological examination, he had flaccid quadriparesis, with severe lower limb weakness;hyperreflexia with ankle clonus and bilateral Babinski signs;bilateral T8-sensory level;and impaired proprioception of the lower limbs. Thoracic CT confirmed COVID-19 pneumonia. MRI scan of the whole spine showed T2 hyperintensity, extending from the cervicomedullary junction to T12 and involving more than two-thirds of the spinal cord transverse section, with associated diffuse enhancement. CSF examination revealed a lymphocyte-predominant pleocytosis (90/L) with moderately elevated protein (1.08g/L) and normal glucose. Laboratory studies, including aquaporin-4-IgG and myelin-oligodendrocyte glycoprotein-IgG, were normal. He was admitted to the intensive care unit for ventilatory support and treatment with remdesivir and IV methylprednisolone was initiated. Conclusion: To our knowledge, this is the case with the most extensive myelitis reported in association with COVID-19 infection. We aim to highlight it and discuss its potential pathogenic mechanisms.