Acute Transverse Myelitis: an upcoming complication of COVID-19 infection

ABSTRACT

Objective: To assess if patients with persistent positive nasopharyngeal polymerase chain reaction (PCR) swab for SARS CoV-2 (COVID-19) virus seem to be at a higher risk of developing complications like acute transverse myelitis (ATM). Background: ATM as post-infectious sequelae was mostly attributed to bacteria-like Mycoplasma pneumonia or viruses like varicella in the pre-pandemic times. However, in the light of the world seeing two waves of the COVID-19, ATM as a post-COVID-19 sequelae is being reported more frequently. Design/Methods: The literature search was done using PubMed and Google scholar using keywords. The search criteria was set to filter cases of ATM in COVID-19 patients, reports between Jan 2020 to July 2021. A total of eight case reports were selected from peer reviewed journals. Results: The reported cases included a total of eight patients ranging from 32-72 years of age. Of the eight case reports, five presented after two weeks of initial COVID-19 symptoms. Seven of the eight patients tested positive for a nasopharyngeal PCR swab for COVID-19 at the time of presentation with ATM symptoms. The most common initial manifestation was acute onset bladder dysfunction and lower limb weakness. In six out of eight cases, magnetic resonance imaging (MRI) of the whole spine showed cervicothoracic cord hyperintensities. Treatment with intravenous methylprednisolone started on day 2 of ATM at a 1g/day dose showed clinical improvement in three patients. Intravenous immunoglobulin therapy (IVIg) at a dose of 25- 30g/day for three days showed improvement in two patients, and one patient improved with plasma exchange following steroid therapy. Conclusions: Most patients with ATM presented with a long latency period (beyond 2 weeks after the initial COVID-19 positive test) and intravenous steroid therapy helps, but most patients seem to require additional IVIg or plasma exchange before showing clinical improvement. We encourage further large scale studies in this regard.