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Table of Contents    
LETTER TO EDITOR
Year : 2021  |  Volume : 69  |  Issue : 5  |  Page : 1479-1480

Parainfectious Longitudinal Extensive Transverse Myelitis (LETM) Post-COVID-19 – A Rare Report


Department of Internal Medicine, VMMC and Safdarjung Hospital, New Delhi, India

Date of Submission17-Mar-2021
Date of Decision11-Apr-2021
Date of Acceptance05-Jul-2021
Date of Web Publication30-Oct-2021

Correspondence Address:
Subramani Jagadeesan
Department of Internal Medicine, VMMC and Safdarjung Hospital, Ansari Nagar West, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.329571

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How to cite this article:
Jagadeesan S, Kamra N, Meena RC, Patel P. Parainfectious Longitudinal Extensive Transverse Myelitis (LETM) Post-COVID-19 – A Rare Report. Neurol India 2021;69:1479-80

How to cite this URL:
Jagadeesan S, Kamra N, Meena RC, Patel P. Parainfectious Longitudinal Extensive Transverse Myelitis (LETM) Post-COVID-19 – A Rare Report. Neurol India [serial online] 2021 [cited 2021 Dec 3];69:1479-80. Available from: https://www.neurologyindia.com/text.asp?2021/69/5/1479/329571




Sir,

The majority of the COVID-19 symptoms appertain with the respiratory system along with a few consistently reported neurological symptoms like transient loss of smell and taste, not to mention the uncommon association of stroke (cerebral infarct/hemorrhage), inflammatory and rarely demyelinating neuropathies.[1] Postviral immune-related acute transverse myelitis (ATM) is the second most common form of ATM. Longitudinally extensive transverse myelitis usually invariably associated with NMO spectrum disorders is being reported here in the aftermath of SARS-CoV-2 infection.

In this report, a 20-year-old college-going Asian female presented with sudden onset of paraplegia, numbness in both lower limbs, acute urinary retention, and constipation for 2 days. Thirteen days prior, she had developed sore throat, nonproductive cough, and fever and was diagnosed with COVID-19. Being uncomplicated, she did not receive any immunomodulatory/antiviral drugs. Her symptoms gradually resolved by around day 10, while on the next day, she started to feel numbness in both lower limbs extending upwards till an inch below both the nipples along with acute urinary retention. She developed difficulty in walking which gradually ascended to the thigh over 2 days. She also reported the absence of bowel movements for 2 days. There was no history of trauma, previous diarrhea, or any recent vaccination. She neither had any medical comorbidities nor was on any prescription/OTC medications. She denied using any recreational substances.

On presentation, she was afebrile, conscious, and comfortable at rest. Two swabs for SARS-CoV-2 RT-PCR were negative. Power of 0/5 (MRC muscle scale) in both the lower limbs the ankle, knee, and hip joints with hypotonia was observed. DTRs were absent in bilateral ankles, knees with a positive Babinski sign. She also exhibited bilateral patchy paresthesia and reduced proprioception (3/5) and vibration (2/5) involving the lower limbs, up to the level of nipples. Neurological examination of both upper limbs was within normal limits. There was decreased sphincter tone on DRE. Higher functions and cranial nerve examinations were normal. A provisional diagnosis of UMN lesion either a spinal cord vascular event or ATM (postviral) was made.

Blood investigations were unremarkable except for anemia of 10.2 g/dL. Contrast-enhanced MRI of the brain and orbits was normal and MRI of the spine revealed long-segment intramedullary ill-defined T2-STIR hyperintensity [as shown in [Figure 1] and [Figure 2] extending from the cervical segment, more prominent on the mid-dorsal level without cord expansion or postcontrast enhancement. Ophthalmic examination revealed no papilledema/optic neuritis. CSF analysis revealed a cell count of 11 with 90% mononuclear cells, minimally elevated protein, (0.81 g/L) and normal glucose levels (66 mg/dL). CSF ADA level was 4.5 U/mL (0–30). Serologies for SARS-CoV-2 and neurotrophic viruses were negative as were the CSF bacterial and fungal cultures. CB-NAAT for Koch's bacilli showed a negative result. Serum ANA, anti-ds DNA, and CSF autoimmune profile including OGB, anti-MOG, etc., were negative by ELISA. A final diagnosis of post-COVID-19 immune-related myelitis was made and she was started on intravenous methylprednisolone 1 g/day. After two days of intravenous steroids, her symptoms improved, and with bladder training, her catheter was removed on day 5. Active physiotherapy and exercises were performed, and she was discharged on oral methylprednisolone after near-complete resolution of her neurological symptoms on day 12. A repeat MRI of the spine after 20 days revealed clearance of spinal hyperintensity that was previously observed.
Figure 1: Transverse section view depicting enhanced hyperintensity involving more than two-thirds of the SC at the mid-dorsall level

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Figure 2: Lateral view of the whole spinal cord showing intramedullary ill-defined T2-STIR hyperintensity of the whole visible cord

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A retrospective study from Wuhan identified that 34% of the COVID-19 patients had one or the other neurological symptoms.[2] Noncompressive myelopathies are characterized by acute to subacute onset of inflammatory spinal cord dysfunction either due to direct invasion of the etiological agent or a noxious substance.[3] In the index case, nonrecurrence of symptoms, involvement of long segment, and normal MR brain study make other demyelinating diseases like MS less likely.[4] The pathogenesis of ATM post-COVID-19 is poorly understood at this time, although the proposed interaction of the virus with the ACE-2 receptor is thought to have a pivotal role in the manifestation of disease.[5] Thus, in this pandemic period, it is wise for the clinicians to hold a differential diagnosis of COVID-19, whenever a patient with unexplained neurological symptoms or diagnosis presents, as an early diagnosis could fairly improve the outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ellul MA, Benjamin L, Singh B, Lant S, Michael BD, Easton A, et al. Neurological associations of COVID-19. Lancet Neurol 2020;19:767-83.  Back to cited text no. 1
    
2.
Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol 2020;77:683-90.  Back to cited text no. 2
    
3.
Chakraborty U, Chandra A, Ray AK, Biswas P. COVID-19–associated acute transverse myelitis: A rare entity. BMJ Case Rep 2020;13:e238668.  Back to cited text no. 3
    
4.
Filippi M, Brück W, Chard D, Fazekas F, Geurts JJG, Enzinger C, et al. Association between pathological and MRI findings in multiple sclerosis. Lancet Neurol 2019;18:198-210.  Back to cited text no. 4
    
5.
Manji H, Carr AS, Brownlee WJ, Lunn MP. Neurology in the time of COVID-19. J Neurol Neurosurg Psychiatry 2020;91:568-70.  Back to cited text no. 5
    


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