Objective:

To describe the clinical characteristics and treatment response of a patient with coronavirus disease (COVID-19) associated myelitis with predominant corticospinal tract involvement.

Background:

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection-related neurological manifestations have been described. Evidence of individuals with COVID-19 associated acute myelitis continue to grow. Various mechanisms have been proposed by which COVID-19 could lead to spinal cord manifestations; an immune-mediated pathogenesis has been considered. However, there is still not a clear distinction between para- and post- infectious presentation of COVID-19 associated myelitis and there are still no specific evidence-based management strategies. For these reasons, it is important to identify and report unusual presentations.

Design/Methods:

We identified a male with few risk factors for severe COVID-19 complications, with sudden onset impaired gait particularly while walking downstairs nine days after the initial presentation of SARS-CoV-2 respiratory symptoms and after receiving a course of nirmatrelvir/ritonavir plus oral steroids. Gait impairment rapidly progressed to leg stiffness and pain of thighs. A second FDA approved COVID-19 booster had been administered months prior to onset.

Results:

Neurologic examination showed lower limbs spasticity, clonus, and corticospinal signs with myalgia of thighs muscles in the absence of weakness, sensory loss, or abnormal sphincter control. CSF showed lymphocytic pleocytosis with elevated proteins; serum inflammatory markers were elevated; viral serology positive for SARS-CoV-2 antigen. Thoraco-lumbar gadolinium MRI was normal. High dose IV steroids were administered with near full recovery.

Conclusions:

SARS-CoV-2 has been associated to several neurological complications. We report a case of pure motor acute-onset rapidly progressing, MRI-negative myelitis, nine days after COVID-19 onset in a vaccinated patient who responded to immunotherapy. To the best of our knowledge, this is the first report of COVID-19 associated myelitis with predominant corticospinal tract involvement without weakness. These findings suggest an immune-mediated pathogenesis and support a combined treatment strategy that needs further investigation.