Plasmapheresis as a fundamental treatment in acute transverse myelitis

ABSTRACT

Background: Acute Transverse Myelitis (ATM) is a very uncommon neurological syndrome, characterized by acute or subacute spinal cord dysfunction that can lead to paresthesias, sensory/autonomic impairment and paralysis. The aetiology is often unclear, but infectious, para-infectious, systemic autoimmune diseases, paraneoplastic, ischemic diseases and drugs are potential causes. Vaccine administration can also trigger an immune response and induce an autoimmune response;however, ATM has rarely been reported as a complication of COVID-19 infections or vaccination. The treatment mainly consists of steroids and plasmapheresis, which often reverses any neurologic symptoms. The therapeutic plasmapheresis is a highly complex procedure. It separates the patient's blood components replacing the plasma removed by solution that can be fresh frozen plasma or albumin, allowing the removal of the autoantibody, immune complex, lipoprotein or endotoxin that's causing the pathology. Aims: Clinical case report. Methods: A 46-year-old male patient, with personal history of hypertension and obesity, 3 weeks after COVID-19 vaccination, presented to the emergency department due to urinary complaints (urgency and pollakiuria), progressive numbness, paresthesias and decreased muscle strength in the lower limbs and decreased sensibility in the perineal region. Physical examination revealed total gait disability, decreased sensation and strength in the right lower limb, loss of sensation and plegia in the left lower limb and urinary incontinence. Initial laboratory workup and CT imaging of the brain, cervical, dorsal and lumbar spine were normal. The patient was admitted to Neurology internment for further study and treatment. During hospitalization, lumbar puncture and MRI of the dorsal and lumbosacral neuraxis were performed, but only allowed us to exclude infectious and compressive etiologies. The inflammatory aetiology was assumed as the most probable, so acute therapy with pulses of methylprednisolone was initiated. In the remaining study, weakly positive anti-MOG (Myelin Oligodendrocyte Glycoprotein) antibodies were detected in the serum. Therapeutic plasmapheresis using a cell separator (which use centrifugal force to separate components according to their density) was proposed as additional therapy. Seven sessions were performed without intercurrences. Results: During acute therapy, there was a partial improvement in sensitivity and strength in lower limbs. The patient started a rehabilitation program with favourable neurological recovery. At the time of hospital discharge, he still needed crutch support for walking and had muscle strength grade 4-/5 bilaterally. Summary/Conclusions: Although the patient maintained some functional limitation and there was not a complete resolution of the neurological symptoms, he showed a good response to acute therapy. The plasmapheresis, by permitting the antibody to be removed faster than would occur by its endogenous clearance, proved to be fundamental in the clinical recovery of the patient. No relationship between COVID-19 vaccination and the event was established.