207 - Late Radiographic Confirmation of COVID-19 Induced Transverse Myelitis

Case Diagnosis: COVID-19 Induced Transverse Myelitis

Case Description: A 77 year old female was hospitalized for COVID-19 pneumonia and subsequently developed bilateral lower extremity weakness. MRI brain was unremarkable. MRI whole spine showed increased signal and abnormal enhancement. Lumbar puncture revealed lymphocytic pleocytosis. Patient was treated with IVIG and discharged home. She developed worsening lower extremity weakness, saddle anesthesia, and bowel/bladder incontinence requiring readmission. Treatment with IV solumedrol and plasmapheresis for possible auto-immune etiology versus paraneoplastic syndrome was given but no improvement. MRI brain and spine was repeated twice and showed no intracranial pathology or abnormal spinal cord signal. Electrodiagnostic studies, anti-acetylcholine antibodies, and repeat lumbar puncture were unremarkable.

Patient was transferred to inpatient rehabilitation for management of lower extremity weakness and paresthesias, autonomic dysreflexia, and bowel/bladder management. She described worsening right hand weakness prompting repeat imaging which showed signal abnormalities consistent with demyelination in the brain and spinal cord confirming suspected clinical diagnosis of transverse myelitis.

Discussions: Transverse myelitis typically presents with a constellation of pain, weakness, sensory alterations, and bowel/bladder dysfunction due to spinal cord inflammation. Etiology is variable but includes auto-immune, infectious, traumatic, and vascular pathologies. In this rare case, a clinical picture of transverse myelitis presented acutely after a COVID-19 infection. However, radiographic findings, an essential component of diagnosis, confirmed a demyelinating process two months after symptom onset. Important to note is that despite worsening symptoms, interval MRI’s did not show radiographic changes. This case highlights that when clinical suspicion is high, repeat imaging to confirm diagnosis is warranted.

Conclusions: Recent literature has elucidated neurological sequelae of COVID-19 including stroke, seizures, and encephalitis. Less common presentations include transverse myelitis. This case showcased evidence of demyelination on imaging, not traditionally associated with COVID-19. Patients with this condition will benefit from an interdisciplinary rehabilitation approach to ensure successful transition back to the community.