Optic neuromyelitis after vaccination against SARS-CoV-2

Abstract

Neuromyelitis optica is an autoimmune demyelinating astrocytopathy of the central nervous system that primarily affects the optic nerve and spinal cord. It is considered a multifactorial disease associated with antibodies against aquaporin 4, with complement cascade activation and lymphocytic infiltration leading to axonal loss and causing significant morbidity and disability. In addition, cases of inflammatory diseases of the central nervous system have been described after vaccination against SARS-CoV-2, mainly acute disseminated encephalomyelitis. Also, a few cases of neuromyelitis optica spectrum disorder, mostly aquaporin 4+, have been reported. We describe a patient who developed symptoms suggestive of acute disseminated encephalomyelitis the next day after vaccination against SARS-CoV-2. Three months later, a longitudinally extensive transverse myelitis compatible with aquaporin 4+ neuromyelitis optica was successfully treated with an interleukin 6 inhibitor. There is no proven association and research is needed to establish whether optic neuromyelitis is related to vaccination; this is a single case report from which no conclusion can be drawn.

Keywords: COVID-19; Immunological products and vaccines; Immunology; Neuroimaging; Neurology (drugs and medicines).

Figure 1

(A) Axial Fluid Attenuated Inversion Recovery (FLAIR) T2 with fat saturation showing lesions in the juxtacortical, deep subcortical borderline and non-borderline white matter, as well as in the corpus callosum. (B) Axial FLAIR T2 with fat saturation showing lesions in both the cerebral peduncles and substantia nigra.

Figure 2

Sagittal Fluid Attenuated Inversion Recovery (FLAIR) T2 image with fat saturation at the midline level showing significant signal alterations in the body and splenium of the corpus callosum and scarcely in the knee, different from those seen in multiple sclerosis (multiple small lesions, Dawson’s finger), both in terms of location and size. In the visualisation of the cervical spine, there are discrete signal changes in the spinal cord at the level of C4. In addition, there is partial sellar arachnoidocele.

Figure 3

(A) Two months after the study, shown in figure 1, the axial Fluid Attenuated Inversion Recovery (FLAIR) T2 image obtained at the same level shows an increase of lesions, mainly in the corpus callosum and other subcortical lesions in the left cerebral hemisphere in the frontoparietal region. In contrast, those observed in the right cerebral hemisphere decreased. (B) At the midbrain level, lesions observed on FLAIR T2 in the cerebral peduncles also reduced in size bilaterally, with an improvement of the substantia nigra and the feet of the midbrain.

Figure 4

Two months after the study, shown in figure 2, the Fast spin echo (FSE) imaging T2 sequence sagittal image of the cervical and dorsal spine shows the spinal cord with substantial signal alterations and an increase in its diameter, which in the previous study were only minimally visible at the C4 level.