Parainfectious Hemorrhagic Longitudinally-extensive Transverse Myelitis Secondary to COVID-19
Alena Makarova1, Sanita Raju2, John Ciotti3
1Neurology, University of South Florida Morsani College of Medicine, 2Neurology, University of South Florida College of Medicine, 3Neurology, University of South Florida
Objective:
To describe a rare presentation of hemorrhagic transverse myelitis in the post-COVID-19 setting.
Background:
Three days after testing positive for COVID-19, a 63-year-old male presented with acute-to-subacute onset of progressive numbness in the right buttocks radiating down his right hip/thigh and across his anterior pelvis, followed shortly thereafter by saddle anesthesia, urinary retention, and neurogenic bowel without motor deficits.
Results:
MRI thoracic/lumbar spine identified longitudinally-extensive T2 hyperintense signal changes from the mid-thoracic cord to conus with edema and patchy posterior-predominant enhancement, cauda equina clumping, and lateral mass effect on the right cord. Brain/cervical spine MRIs were without any suspicious lesions. Extensive serum workup for inflammatory (including NMOSD/MOGAD), metabolic, and infectious causes of myelitis was unremarkable. CSF results were confounded by traumatic tap, but they were not concerning for infection or neoplasm. Clinical presentation was felt to be incompatible with ischemic or direct infectious causes. Based on this and extensive workup above, presumptive diagnosis of parainfectious hemorrhagic transverse myelitis was made. He completed 5 days of high-dose IV methylprednisolone with considerable symptomatic improvement. Additional outpatient testing including spinal angiogram was unremarkable. Follow-up thoracic/lumbar spine MRIs revealed radiologic improvement with residual distal cord T2 hyperintensity surrounded by multiloculated changes compatible with prior hemorrhage and continued cauda equina clumping despite near-complete symptomatic recovery.
Conclusions:
Parainfectious hemorrhagic transverse myelitis secondary to COVID-19 infection has been previously reported. However, this case is differentiated by good clinical recovery despite longitudinally-extensive involvement. We highlight the importance of extensive workup for other causes of acute myelitis including neuroinflammatory, metabolic, neoplastic, and vascular etiologies (including acute ischemia and dural AV fistula). Clinicians should be aware of acute parainfectious hemorrhagic myelitis secondary to COVID-19 and other viral infections as patients can develop significant disability if treatment is not urgently initiated.