A Pediatric Case of Severe, Treatment-Resistant, COVID-19 Associated Acute Longitudinally Extensive Transverse Myelitis with Masquerading Confounding Variables

ABSTRACT

Objective: To report a pediatric case of severe, treatment-resistant, COVID-19-associated acute longitudinally extensive transverse myelitis (LETM). Background: Since the COVID-19 global pandemic, there is evolving literature reporting the neurological manifestations of the novel coronavirus. COVID-19-associated acute LETM was first reported in an elderly Asian man with lower-extremity weakness <1-week after onset of fever and respiratory distress. In childhood, this is rarely reported with only few reports of COVID-19-associated acute LETM. Design/Methods: We reviewed clinical and radiographic reports of our patient. We searched PubMed for literature using terms “transverse myelitis & COVID-19” and “pediatric transverse myelitis&COVID-19.” Results: A 5-year-old previously healthy boy presented with altered mental status. Prior to admission, he was exposed to COVID-19 and had consumed an unknown quantity of sertraline and risperidone tablets. Thereafter, he stated that he could not feel his legs, fell, and hit his head. In the emergency department, he was intubated. EKG revealed QTc prolongation (486-ms). SARS-CoV-2-PCR positive. Thereafter, flaccid quadriparesis, bulbar dysfunction, left-sided numbness, and hyperreflexia were noted;he communicated by eye blinking. MRI-spine revealed C1-C4 hyperintensity (T2-weighted) consistent with LETM;DWI negative for acute stroke. CSF basic labs, viral and MS panels, and ACE unremarkable. Serum anti-aquaporin-4 and myelin-oligodendrocyte-glycoprotein antibodies negative. Serum West Nile-IgM-IgG negative. Mycoplasma pneumoniae IgM-reactive, IgG-positive;confirmatory IgM immunofluorescence assay-negative. He received IV-methylprednisolone ×5-days, plasmapheresis ×10-sessions, pulsed steroid ×3-days. Minimal neurological improvement was noted. Repeat MRI-spine 2-weeks later unchanged. Tracheostomy and gastric tube were placed. He was transferred to a neurology topic. Conclusions: COVID-19-associated acute LETM in childhood can have a rapid, devastating clinical course. Clinicians should maintain a high-index of suspicion for LETM in COVID-19 pediatric patients presenting with neurological manifestations and consider alternative strategies for severe, treatment-resistant cases.