Central nervous system (CNS) inflammatory demyelinating diseases (IDDs) associated with COVID-19: A case series and review

Abstract

Background: Over the past two years, SARS-CoV-2 has frequently been documented with various post and para-infectious complications, including cerebrovascular, neuromuscular, and some demyelinating conditions such as acute disseminated encephalomyelitis (ADEM). We report two rare neurological manifestations post-COVID-19 infection; multiple sclerosis (MS) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). Further, we reviewed other CNS inflammatory demyelinating diseases (IDDs) associated with SARS-CoV-2, including optic neuritis (ON) and neuromyelitis optica spectrum disorders (NMOSD).

Methods: A descriptive analysis and literature search of Google Scholar and PubMed was conducted by two independent reviewers from December 1st, 2019, to March 30th, 2022, and included all the case studies of MS, MOGAD, NMOSD, and ON associated with COVID-19 infection.

Case presentations: Case 1 (MS) was a 24-year-old female with paresthesia and bilateral weakness one week after COVID-19 symptom onset who showed demyelinating plaques and 12 isolated oligoclonal bands (OCBs). Case 2 (MOGAD) was a 41-year-old male with encephalomyelitis 16 days after COVID-19, who later developed MOG-antibody-associated optic neuritis.

Results: Out of 18 cases, NMOSD was the most common post-COVID manifestation (7, 39%), followed by MOGAD (5, 28%), MS (4, 22%), and isolated ON (2, 11%). The median duration between the onset of COVID-19 symptom onset and neurological symptoms was 14 days. 61% of these were male, with a mean age of 35 years. IVMP was the treatment of choice, and nearly all patients made a full recovery, with zero fatalities.

Conclusions: Although these neurological sequelae are few, physicians must be cognizant of their underlying pathophysiology and associated clinical and neuro-diagnostic findings when treating COVID-19 patients with atypical presentations.

Keywords: CNS IDD; COVID-19; MOGAD; MS; NMOSD; Optic neuritis;; SARS-CoV-2; Virus-induced demyelination.

Fig. 1

MRI Brain sagittal FLAIR images 1(A) showed ovoid periventricular white matter lesion (yellow arrows) and left temporal lesion and corresponding enhancement on axial images 1(B) (yellow arrow) & 1(C) (orange arrow). MRI sagittal STIR images 1(D) of the cervical spine reveal patchy multiple short segment hyperintensity with prominent cord lesion at C2-C3, C4-C5, C5-C6 (yellow arrow), and 1(E) post-contrast sagittal image showed abnormal enhancement at C4-C5 (orange arrow). MRI sagittal STIR image (1F) of the thoracic spine showed intramedullary mid-thoracic cord lesion at T6-T8 (yellow arrow) with corresponding abnormal enhancement at T6 (orange arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 2

MRI orbit Axial T1- weighted pre-contrast 2(A) and post-contrast 2(B) reveals abnormal enhancement of left optic nerve prechiasmatic (intracanalicular); (orange arrow). Fig. 2(C) Optical Coherence Test (OCT) showing baseline and follow-up retinal nerve fiber layer thickness with thinned ganglion cell layer and overall stable rest of the retinal layer on the left compared to the right. MRI sagittal STIR images 2(D) of the cervical spine reveal patchy short segment hyperintensity with prominent cord lesion at C2, C4-C5 (yellow arrow); 2(E) shows axial cut with cord signal alteration at C4-C5 (yellow arrow), and 2(F) post-contrast sagittal image showed abnormal enhancement at C2 (orange arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)