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.