A Tale of Two Afflictions: Transverse Myelitis and COVID-19 in a Young Female Patient

Abstract

Acute transverse myelitis (ATM) is a syndrome of multiple etiologies, with acute or subacute onset in which inflammation of the spinal cord results in neurological deficits, including weakness, sensory loss, and autonomic dysfunction. It is often associated with infectious or autoimmune etiologies but can be considered idiopathic when extensive workup is negative. We present a case of a young African American female who presented with acute onset of bilateral lower extremity weakness, loss of sensation, and autonomic dysfunction. On physical exam, she had absent lower extremity reflexes, 0-1/5 power, and markedly diminished sensation with no pain/temperature discrimination with an abdominal sensory level at T4. There was no upper extremity involvement. She was incidentally found to be COVID-19-positive and denied ever being vaccinated in the past. MRI of the spine revealed diffuse signal abnormality within the cervical and thoracic spine extending to the conus, and an MRI of the brain showed two white matter lesions in the frontal lobes. Lumbar puncture showed lymphocytic pleocytosis and elevated protein; Gram stain did not reveal any pathogen. The patient was treated initially with high doses of steroids with minimal response. She underwent multiple sessions of plasmapheresis with good tolerance and response. Differential diagnoses considered for this case were Guillain Barre syndrome, neuromyelitis optica (NMO), multiple sclerosis, SLE-induced transverse myelitis, or infectious cases. All lab work and workup came back negative for these diseases, leaving us with an interesting culprit: COVID-19 associated. There have been few cases mentioned in the literature of transverse myelitis caused by COVID-19, and this remains a possibility, as all other causes were ruled out.

Keywords: acute transverse myelitis (atm); covid 19; covid 19 encephalitis; neuromyelitis optica spectrum disorder; viral transverse myelitis.

Figure 1. Magnetic resonance imaging (MRI) lumbar spine with and without contrast

Diffuse signal abnormality seen within the cervical and thoracic cord, extending to the conus

Figure 2. Magnetic resonance imaging (MRI) brain without contrast, sagittal FLAIR sequence

Diffuse signal abnormality seen within the medulla extending into the visualized upper cervical cord seen to the C4 level FLAIR: fluid-attenuated inversion recovery

Figure 3. Magnetic resonance imaging (MRI) brain without contrast

Larger area of subcortical FLAIR hyperintensity seen within the left frontal lobe, which has an oval configuration Fluid-attenuated inversion recovery

Figure 4. Magnetic resonance imaging (MRI) without contrast

Focal area of oval shape signal abnormality seen within the subcortical white matter of the right posterior frontal lobe