Discussion
Acute transverse myelitis (ATM) is characterized by localized
inflammation of certain spinal cord segments. It is uncertain that it is
due to direct viral invasion or by an autoimmune response to
(SARS-CoV-2) virus. The diagnosis of ATM is made based on characteristic
clinical findings in addition to serologic, MRI, and CSF analysis. The
incidence rate of idiopathic ATM has been estimated to be between one
and eight new cases per million annually. 4
The incidence of neurologic involvement in patients diagnosed with
SARS-CoV-2 is variable from 6 to 36.4%. 5 SARS-CoV-2
binds to ACE-2 receptors strongly in the lungs, heart, central nervous
system, and skeletal muscles. 6
The viral replication and activation of ACE-2 receptor in the CNS may
trigger a systemic inflammatory response. 6,7 IL-6, a
proinflammatory cytokine, has been thought to mediate this response, and
in our case, IL-6 was (97 pg/mL).
T2-weighted MRI is the imaging modality of choice to detect any spinal
cord lesions; MRI’s role is not limited to detect spinal cord lesions
but also to rule out other differential diagnoses that may mimic the
same clinical symptoms. Signal changes tend to affect the central region
of the cord and involve more than two-thirds of the diameter of the cord
as well as extend longitudinally over more than 1 segment in acute
myelitis. The affected spinal cord segments appear hyperintense on T2
sequences with associated cord swelling.8,9
There is no curative treatment for transverse
myelitis10; therefore, preventing or minimizing
permanent neurological deficits is the main purpose of ATM’s treatment.
Treatment options include corticosteroid or plasmapheresis if there is
an inadequate response to initial treatment.
The first case of acute myelitis due to SARS-CoV-2 was reported in
Wuhan, China in March 2020. A male patient (66 years old) who had no
known contact with patients with COVID-19 was presented with fever and
fatigue for two days. Later, he was discharged to a rehabilitation
facility to continue his treatment due to post-infection spinal cord
involvement.11
The second case was reported in May 2020 in Denmark, for a young (28
years) female patient who presented with urinary retention, lower back
pain, and generalized numbness. Intravenous corticosteroids and plasma
exchange had significantly improved her symptoms.12
The third case was reported in June 2020, where a 61-year-old female
patient presented with similar symptoms like our case; however, the ATM
led to a permanent neurologic impairment requiring extensive
rehabilitation.13
To our knowledge, this is the fourth reported case of ATM due to
SARS-CoV-2 worldwide. Our case is a bit different where the patient
devastatingly died during the index admission probably from SARS-CoV-2
related complications like acute pulmonary embolism, fulminant
myocarditis, or cytokine storm.