Longitudinal Extensive Transverse Myelitis:rare immunotherapy related adverse effect vs COVID19-related immunization complication

ABSTRACT

Objective: To report an acute presentation of long extensive transverse myelitis (LETM) in the setting of Atezolizumab monotherapy and COVID-19 mRNA immunization Background: Patients being treated with immune checkpoint inhibitors (ICI) for advanced malignancy have an increased propensity of developing neuro-immune complications. With the advent of the COVID-19 pandemic there have been reported cases of TM following COVID-19 immunization. The reported infrequency of TM with both aforementioned causes makes delineating the etiology challenging. Design/Methods: A 58-year-old male with metastatic SCLC completed 4 cycles of Atezolizumab, Carboplatin and Etoposide and was transitioned to Atezolizumab maintenance. He previously underwent Atezolizumab infusion and was administered the second dose of COVID-19 mRNA vaccine one day prior to developing acute lower extremity paralysis, sensory loss from chest down and overflow incontinence. MRI spine illustrated centromedullary enhancing lesions from C7-T7. CSF analysis showed 25 WBC, 116/uL RBC, 94 mg/dL protein, normal glucose, negative oligoclonal bands and normal IgG index. CSF bacterial and virology studies were negative. Additionally, serum anti-myelin oligodendrocyte glycoprotein (MOG) and antiaquaporin receptor 4 (AQP4) antibodies were unremarkable. Results: 5-day course of pulsed methylprednisolone followed by three therapeutic plasma exchanges produced minimal improvement in lower extremities strength and sensory level. Conclusions: This case demonstrates the complication and symptomatology of TM in the setting of anti-PD-L1 monoclonal antibody with the co-incidental COVID-19 mRNA vaccine administration. The causal relationship between the vaccine and TM is difficult to establish due to limited data and the presence of a known inciting factor but hints at a possible exaggeration of the existing neuroinflammatory process. Currently, CDC recommends that individuals who are moderately to severely immunocompromised receive an additional dose of an mRNA COVID-19 Vaccine (Pfizer-BioNTech or Moderna) at least 28 days after the completion of the initial mRNA COVID-19 vaccine series. Caution should be given for those patients who are on ICI therapy.