Corticospinal and Dorsal Column Tractopathy in the Setting of Preceding COVID-19 Infection
Objective:
To present a case of initially imaging-negative myelitis following COVID-19 infection, with repeat imaging demonstrating lateral tract longitudinally extensive myelitis responding to immunotherapy.
Background:
Lateral and dorsal column tractopathy has been described in cases of paraneoplastic myelitis with generally poor prognosis despite immunotherapy. Few cases similar to ours have been described in association with COVID-19 infection, with good outcome with immunotherapy.
Design/Methods:
There is a single case presented in this imaging highlight. Data was collected in a retrospective manner using available medical records and radiology images and reports.
Results:
A 49-year-old man presented to hospital with a 5-week history of progressive sensorimotor deficits affecting this ability to ambulate. He had mild COVID-19 infection four weeks prior to symptom onset. Examination revealed progressive weakness and hyperreflexia with severe sensory ataxia and T5 spinal sensory level. MRI brain and spine and extensive investigations for infectious, autoimmune, malignant, metabolic, and genetic causes were unremarkable. He received empiric immunotherapy for clinically suspected imaging-negative myelitis. Repeat MRI revealed linear, increased T2 signal in the posterior limb of the internal capsule and midbrain and subtle symmetric longitudinally extensive increased T2 signal within the lateral columns extending from the craniocervical junction to the conus. He had clinical and radiologic improvement following plasmapheresis and maintenance intravenous immunoglobulin therapy.
Conclusions:
These unique neuroimaging findings further reinforce the expanding spectrum of neurological manifestations of COVID-19, specifically a lateral tract longitudinal extensive myelitis. Patients may actually have a better prognosis compared to the similar pattern seen in paraneoplastic myelitis. Neuroimaging findings may occur later despite significant early neurological deficits, highlighting the importance of clinical suspicion and repeat imaging.