COVID-19-associated myelitis: Difference between revisions

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{{SI}}
{{SI}}


{{CMG}}; {{AE}}
{{CMG}}; {{AE}} {{sali}} [[User:Tayebah Chaudhry|Tayebah Chaudhry]][mailto:dr.thch@yahoo.com], {{Fs}}


{{SK}}  
{{SK}}  


==Overview==
==Overview==
In the current [[pandemic]] state, [[COVID-19]] should be considered as a differential diagnosis in a patient presenting with acute [[myelitis]]. Acute Transverse Myelitis is a neurological condition characterized by inflammation and injury of the [[spinal cord]]. In a confirmed or newly diagnosed patient of COVID-19, it is thought to be either a direct consequence of viral infection or a sequalae of [[autoimmune]]-mediated response. COVID-19-associated myelitis is diagnosed based on the hallmark symptoms of acute myelitis and confirmed with changes on spinal MRI, after ruling out other possible etiologies of myelitis. The symptoms show marked improvement after treatment with [[steroids]] and [[plasma exchange]].


==Historical Perspective==
==Historical Perspective==
[Disease name] was first discovered by [name of scientist], a [nationality + occupation], in [year]/during/following [event].


The association between [important risk factor/cause] and [disease name] was made in/during [year/event].
* First case of acute [[myelitis]] as a [[COVID-19]] complication was reported in February 2020 in Wuhan by Kang Zhao et al, in a 66 year old male patient. <ref name="urlwww.medrxiv.org">{{cite web |url=https://www.medrxiv.org/content/10.1101/2020.03.16.20035105v1.full.pdf |title=www.medrxiv.org |format= |work= |accessdate=}}</ref>
 
* The second case was reported in Boston by Sarma et al in a 28 year old female patient who developed acute myelitis 7 days after symptoms of [[upper respiratory tract infection]]. <ref name="urlA Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection">{{cite web |url=https://escholarship.org/uc/item/0mj588gb |title=A Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection |format= |work= |accessdate=}}</ref>
In [year], [scientist] was the first to discover the association between [risk factor] and the development of [disease name].
*As of now, only few case reports have been published in literature showing an association of COVID-19 with acute myelitis as a neurological complication.
 
In [year], [gene] mutations were first implicated in the pathogenesis of [disease name].
 
There have been several outbreaks of [disease name], including -----.
 
In [year], [diagnostic test/therapy] was developed by [scientist] to treat/diagnose [disease name].


==Classification==
==Classification==
There is no established system for the classification of [disease name].


OR
* There is no established system for the classification of COVID-19-associated myelitis.
 
[Disease name] may be classified according to [classification method] into [number] subtypes/groups: [group1], [group2], [group3], and [group4].
 
OR
 
[Disease name] may be classified into [large number > 6] subtypes based on [classification method 1], [classification method 2], and [classification method 3].
[Disease name] may be classified into several subtypes based on [classification method 1], [classification method 2], and [classification method 3].
 
OR
 
Based on the duration of symptoms, [disease name] may be classified as either acute or chronic.
 
OR
 
If the staging system involves specific and characteristic findings and features:
According to the [staging system + reference], there are [number] stages of [malignancy name] based on the [finding1], [finding2], and [finding3]. Each stage is assigned a [letter/number1] and a [letter/number2] that designate the [feature1] and [feature2].
 
OR
 
The staging of [malignancy name] is based on the [staging system].
 
OR
 
There is no established system for the staging of [malignancy name].


==Pathophysiology==
==Pathophysiology==
The exact pathogenesis of [disease name] is not fully understood.
OR


It is thought that [disease name] is the result of / is mediated by / is produced by / is caused by either [hypothesis 1], [hypothesis 2], or [hypothesis 3].
*The [[pathogenesis]] of the [[disease]] behind this manifestation is not fully understood yet.
 
*There is a strong evidence suggesting that [[COVID-19]] [[virus]] uses [[angiotensin-converting enzyme]]2 (ACE2) as its [[receptor]] to interact with [[host cell]]s.  
OR
*This evidence is based on the previous extensive [[SARS-CoV]] structural analyses that showed interactions between the [[SARS-CoV]] [[virus]] and [[ACE2 receptor]]s and because of the marked sequence similarities between [[Covid-19]] and the [[SARS-CoV]] [[virus]] it is hypothesized that [[COVID 19]] [[virus]] [[pathogenesis]] is comparable.
 
*The [[ACE2 receptor]]s are expressed on [[alveolar epithelial cell]]s, [[intestinal enterocytes]] and [[arterial]] and [[venous]] [[endothelial cell]]s.
[Pathogen name] is usually transmitted via the [transmission route] route to the human host.
*In the brain, only the vascular cells expressed ACE2 cell receptors, not the neurons; yet attachment of the virus to the vascular endothelium this could be a potential mechanism for dissemination of the virus into the brain by the blood circulation<ref name="pmid32312872">{{cite journal| author=Manji H, Carr AS, Brownlee WJ, Lunn MP| title=Neurology in the time of COVID-19. | journal=J Neurol Neurosurg Psychiatry | year= 2020 | volume= 91 | issue= 6 | pages= 568-570 | pmid=32312872 | doi=10.1136/jnnp-2020-323414 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32312872  }} </ref>.
 
*It is also hypothesized that the virus can disseminate into the nervous system through the olfactory bulb in which sensory neurons connect the nasal cavity to the central nervous system by the axons, which terminate in the olfactory bulb and passes through the cribriform plate<ref name="pmid31996437">{{cite journal| author=Wan Y, Shang J, Graham R, Baric RS, Li F| title=Receptor Recognition by the Novel Coronavirus from Wuhan: an Analysis Based on Decade-Long Structural Studies of SARS Coronavirus. | journal=J Virol | year= 2020 | volume= 94 | issue= 7 | pages=  | pmid=31996437 | doi=10.1128/JVI.00127-20 | pmc=7081895 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31996437  }} </ref>.
OR
*Early‐phase [[COVID‐19]]‐affected patients may exhibit loss of smell and taste as a result of this <ref name="pmid32266761">{{cite journal| author=Baig AM| title=Neurological manifestations in COVID-19 caused by SARS-CoV-2. | journal=CNS Neurosci Ther | year= 2020 | volume= 26 | issue= 5 | pages= 499-501 | pmid=32266761 | doi=10.1111/cns.13372 | pmc=7163592 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32266761  }} </ref>.
 
*In advanced stages of the disease the [[neurological]] [[signs and symptom]]s observed with [[COVID‐19]] could also be due to the effects of [[hypoxia]], [[respiratory]], and [[metabolic acidosis]]<ref name="Pastor BandeiraMachado Schlindwein2020">{{cite journal|last1=Pastor Bandeira|first1=Isabelle|last2=Machado Schlindwein|first2=Marco Antônio|last3=Breis|first3=Leticia Caroline|last4=Schatzmann Peron|first4=Jean Pierre|last5=Magno Gonçalves|first5=Marcus Vinicius|year=2020|doi=10.20944/preprints202004.0304.v1}}</ref>.
Following transmission/ingestion, the [pathogen] uses the [entry site] to invade the [cell name] cell.
 
OR
 
 
[Disease or malignancy name] arises from [cell name]s, which are [cell type] cells that are normally involved in [function of cells].
 
OR
 
The progression to [disease name] usually involves the [molecular pathway].
 
OR
 
The pathophysiology of [disease/malignancy] depends on the histological subtype.


==Causes==
==Causes==
Disease name] may be caused by [cause1], [cause2], or [cause3].
OR
Common causes of [disease] include [cause1], [cause2], and [cause3].
OR


The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].
Apart from [[COVID-19]] other causes of viral myelitis include<ref name="pmid26209588">{{cite journal| author=Pekcevik Y, Mitchell CH, Mealy MA, Orman G, Lee IH, Newsome SD | display-authors=etal| title=Differentiating neuromyelitis optica from other causes of longitudinally extensive transverse myelitis on spinal magnetic resonance imaging. | journal=Mult Scler | year= 2016 | volume= 22 | issue= 3 | pages= 302-11 | pmid=26209588 | doi=10.1177/1352458515591069 | pmc=4797654 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26209588  }} </ref>:


OR
*[[Herpes viruse]]s, including the one that causes [[shingles]] and [[chickenpox]] ([[zoster]])
*[[Cytomegalovirus]]
*[[Epstein-Barr]]
*[[HIV]]
*[[Enteroviruses]] such as [[poliovirus]] and [[coxsackievirus]]
*[[West Nile]]
*[[Echovirus]]
*[[Zika]]
*[[Influenza]]
*[[Hepatitis B]]
*[[Mumps]], [[measles]] and [[rubella]]


The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click [[Pericarditis causes#Overview|here]].
Other causes of myelitis are:
*[[Bacterial myelitis]]
*[[Fungal myelitis]]
*[[Parasitic myelitis]]
*[[Multiple Sclerosis]]
*[[Transverse Myelitis]]
*[[Autoimmune]] disorders like [[SLE]] and [[Sjogren’s Syndrome]]
*[[Sarcoidosis]]
*[[Vaccinations]]


==Differentiating COVID-19-associated myelitis from other Diseases==
==Differentiating COVID-19-associated myelitis from other Diseases==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
OR


[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
*For further information about the differential diagnosis, [[COVID-19-associated myelitis differential diagnosis|click here]].
*To view the differential diagnosis of COVID-19, [[COVID-19 differential diagnosis|click here]].


==Epidemiology and Demographics==
==Epidemiology and Demographics==
The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.
OR


In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.
* As of now, the incidence of acute myelitis associated with Covid-19 infection in unknown. <ref name="AlKetbiAlNuaimi2020">{{cite journal|last1=AlKetbi|first1=Reem|last2=AlNuaimi|first2=Dana|last3=AlMulla|first3=Muna|last4=AlTalai|first4=Nouf|last5=Samir|first5=Mohammed|last6=Kumar|first6=Navin|title=Acute Myelitis as a Neurological Complication ofCovid-19:A Case Report and MRI Findings|journal=Radiology Case Reports|year=2020|issn=19300433|doi=10.1016/j.radcr.2020.06.001}}</ref><ref name="pmid32458198">{{cite journal| author=Munz M, Wessendorf S, Koretsis G, Tewald F, Baegi R, Krämer S | display-authors=etal| title=Acute transverse myelitis after COVID-19 pneumonia. | journal=J Neurol | year= 2020 | volume=  | issue=  | pages=  | pmid=32458198 | doi=10.1007/s00415-020-09934-w | pmc=7250275 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32458198  }} </ref>
 
*To view epidemiology and demographics for COVID-19, [[COVID-19 epidemiology and demographics|click here]].<br />
OR
 
In [year], the incidence of [disease name] is approximately [number range] per 100,000 individuals with a case-fatality rate of [number range]%.
 
 
 
Patients of all age groups may develop [disease name].
 
OR
 
The incidence of [disease name] increases with age; the median age at diagnosis is [#] years.
 
OR
 
[Disease name] commonly affects individuals younger than/older than [number of years] years of age.
 
OR
 
[Chronic disease name] is usually first diagnosed among [age group].
 
OR
 
[Acute disease name] commonly affects [age group].
 
 
 
There is no racial predilection to [disease name].
 
OR
 
[Disease name] usually affects individuals of the [race 1] race. [Race 2] individuals are less likely to develop [disease name].
 
 
 
[Disease name] affects men and women equally.
 
OR
 
[Gender 1] are more commonly affected by [disease name] than [gender 2]. The [gender 1] to [gender 2] ratio is approximately [number > 1] to 1.
 
 
 
The majority of [disease name] cases are reported in [geographical region].
 
OR
 
[Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].


==Risk Factors==
==Risk Factors==
There are no established risk factors for [disease name].
OR
The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].
OR
Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].


OR
* There are no established risk factors for COVID-19-associated myelitis. However, since this condition is a direct consequence of infection by the novel coronavirus, risk factors for [[COVID-19]] should be considered.
 
*To view the risk factors of COVID-19, [[COVID-19 risk factors|click here]].
Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.


==Screening==
==Screening==
There is insufficient evidence to recommend routine screening for [disease/malignancy].


OR
* Screening for COVID-19-associated myelitis is not currently done.
 
* To view screening for COVID-19, [[COVID-19 screening|click here]].<br />
According to the [guideline name], screening for [disease name] is not recommended.
 
OR
 
According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
OR


Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
'''Natural History'''
* Myelitis associated with COVID-19 is an acute condition. The first case of COVID-19 associated myelitis developed the symptoms 5 days after the onset of fever. <ref name="urlwww.medrxiv.org">{{cite web |url=https://www.medrxiv.org/content/10.1101/2020.03.16.20035105v1.full.pdf |title=www.medrxiv.org |format= |work= |accessdate=}}</ref>
*The second case developed symptoms of myelitis 7 days after the upper respiratory symptoms. <ref name="urlA Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection">{{cite web |url=https://escholarship.org/uc/item/0mj588gb |title=A Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection |format= |work= |accessdate=}}</ref>


OR
'''Complications'''
*Lack of prompt recognition and management may result in lasting neurological complications (such as residual loss of sensation in lower extremities) after novel corona virus infection. <ref name="urlA Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection">{{cite web |url=https://escholarship.org/uc/item/0mj588gb |title=A Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection |format= |work= |accessdate=}}</ref>


Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.
'''Prognosis'''
*Exact prognosis of COVID-19-associated myelitis is not known.
*Marked improvement in symptoms is seen with steroids and plasma exchange.


==Diagnosis==
==Diagnosis==
===Diagnostic Study of Choice===
===Diagnostic Study of Choice===
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
OR
The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
OR
The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
OR


There are no established criteria for the diagnosis of [disease name].
*Diagnosis of COVID-19-associated myelitis is based on the hallmark symptoms of acute myelitis in a known case of COVID-19 or a positive [[PCR]] nasal swab for COVID-19 in a new patient. And classic contrast-enhancing lesions on MRI spine.
*Hallmark symptoms of acute myelitis include bilateral symmetric weakness and sensory changes in extremities, [[urinary retention]] and lower back pain.
*Absence of visual symptoms such as eye pain or vision loss ( classically seen in [[Multiple Sclerosis]] or [[Neuromyelitis optica]]), negative immunoglobulin G auto-antibodies or [[oligoclonal bands]], negative [[anti-nuclear antibody]] ([[ANA]]) test (very sensitive test for [[autoimmune]] diseases such as [[lupus]]), absence of other system involvement (such as skin rash, nodules, cardiac [[arrhythmias]] or [[arthritis]] seen in lupus or [[sarcoidosis]]) rule out other possible etiologies. <ref name="AlKetbiAlNuaimi2020">{{cite journal|last1=AlKetbi|first1=Reem|last2=AlNuaimi|first2=Dana|last3=AlMulla|first3=Muna|last4=AlTalai|first4=Nouf|last5=Samir|first5=Mohammed|last6=Kumar|first6=Navin|title=Acute Myelitis as a Neurological Complication ofCovid-19:A Case Report and MRI Findings|journal=Radiology Case Reports|year=2020|issn=19300433|doi=10.1016/j.radcr.2020.06.001}}</ref>


===History and Symptoms===
===History and Symptoms===
The majority of patients with [disease name] are asymptomatic.
'''Common symptoms'''
*[[Paraplegia]] <ref name="AlKetbiAlNuaimi2020">{{cite journal|last1=AlKetbi|first1=Reem|last2=AlNuaimi|first2=Dana|last3=AlMulla|first3=Muna|last4=AlTalai|first4=Nouf|last5=Samir|first5=Mohammed|last6=Kumar|first6=Navin|title=Acute Myelitis as a Neurological Complication ofCovid-19:A Case Report and MRI Findings|journal=Radiology Case Reports|year=2020|issn=19300433|doi=10.1016/j.radcr.2020.06.001}}</ref>


OR
*[[Urinary retention]] <ref name="AlKetbiAlNuaimi2020">{{cite journal|last1=AlKetbi|first1=Reem|last2=AlNuaimi|first2=Dana|last3=AlMulla|first3=Muna|last4=AlTalai|first4=Nouf|last5=Samir|first5=Mohammed|last6=Kumar|first6=Navin|title=Acute Myelitis as a Neurological Complication ofCovid-19:A Case Report and MRI Findings|journal=Radiology Case Reports|year=2020|issn=19300433|doi=10.1016/j.radcr.2020.06.001}}</ref>
* Lower back pain <ref name="urlA Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection">{{cite web |url=https://escholarship.org/uc/item/0mj588gb |title=A Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection |format= |work= |accessdate=}}</ref>
* Weakness in lower extremities <ref name="AlKetbiAlNuaimi2020">{{cite journal|last1=AlKetbi|first1=Reem|last2=AlNuaimi|first2=Dana|last3=AlMulla|first3=Muna|last4=AlTalai|first4=Nouf|last5=Samir|first5=Mohammed|last6=Kumar|first6=Navin|title=Acute Myelitis as a Neurological Complication ofCovid-19:A Case Report and MRI Findings|journal=Radiology Case Reports|year=2020|issn=19300433|doi=10.1016/j.radcr.2020.06.001}}</ref>


The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].
'''Less common symptoms'''
* [[Paresthesias]] in lower extremities with possible ascension to upper extremities <ref name="urlA Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection">{{cite web |url=https://escholarship.org/uc/item/0mj588gb |title=A Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection |format= |work= |accessdate=}}</ref>
* [[Numbness]] in lower extremities with possible ascension to upper extremities<ref name="urlA Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection">{{cite web |url=https://escholarship.org/uc/item/0mj588gb |title=A Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection |format= |work= |accessdate=}}</ref>
* Numbness in tip of tongue <ref name="urlA Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection">{{cite web |url=https://escholarship.org/uc/item/0mj588gb |title=A Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection |format= |work= |accessdate=}}</ref>


===Physical Examination===
===Physical Examination===
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].


OR


Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].


OR
'''Vitals:'''
 
Abnormal vitals can be seen due to [[COVID-19]] association. These include:
*Decreased O2 saturation
*[[Tachycardia]]
*[[Tachypnea]]


The presence of [finding(s)] on physical examination is diagnostic of [disease name].
'''Abdominal exam:'''
*Palpable [[Bladder distension|distended bladder]]


OR
'''Neurological exam:'''


The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
Neurological findings are symmetric and more severe in lower [[extremities]]. <ref name="urlwww.medrxiv.org">{{cite web |url=https://www.medrxiv.org/content/10.1101/2020.03.16.20035105v1.full.pdf |title=www.medrxiv.org |format= |work= |accessdate=}}</ref>
<ref name="urlA Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection">{{cite web |url=https://escholarship.org/uc/item/0mj588gb |title=A Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection |format= |work= |accessdate=}}</ref>
<ref name="AlKetbiAlNuaimi2020">{{cite journal|last1=AlKetbi|first1=Reem|last2=AlNuaimi|first2=Dana|last3=AlMulla|first3=Muna|last4=AlTalai|first4=Nouf|last5=Samir|first5=Mohammed|last6=Kumar|first6=Navin|title=Acute Myelitis as a Neurological Complication ofCovid-19:A Case Report and MRI Findings|journal=Radiology Case Reports|year=2020|issn=19300433|doi=10.1016/j.radcr.2020.06.001}}</ref>
*Wide based [[gait]]
*Decreased muscle strength
*Decreased sensation
*Decreased [[proprioception]]
*[[Hyporeflexia]]
*[[Paresthesias]]
*Positive [[Lhermitte's sign]]
*Positive [[Babinski's sign]] bilaterally.


===Laboratory Findings===
===Laboratory Findings===
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].


OR
'''Nasal swab:'''
 
* [[PCR]] nasal swab may give positive result for [[COVID-19]].


Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
'''Other Viral Screening:'''
*Viral [[PCR]] screening including [[Adenovirus]], [[Herpes Simplex Virus]] (Type 1&2), [[Epstein barr virus mononucleosis|Epstein Barr Virus]], [[Cytomegalovirus]], [[Human Immunodeficiency Virus]] ([[HIV]]) will yield negative results.
*Viral serology for [[Influenza]] Virus A and B, [[Parainfluenza]] 1-4, [[Respiratory Syncytial]] virus, [[Enterovirus]] and [[Rhinovirus]] with negative results.
*Negative antibody results for bacteria such as [[Chlamydia]] Pneumoniae, [[Bordetella]] Pertussis, [[Mycoplasma]] Pneumoniae and [[Borrelia]].


OR
'''MRI spine:'''


[Test] is usually normal among patients with [disease name].
* [[MRI]] findings consistent with Acute Transverse Myelitis (involving more than three [[spinal cord]] segments) are seen. This includes widespread elongated signal changes throughout the [[Grey matter|gray matter]] of [[spinal cord]], with no disc pathology or [[spinal canal]] narrowing. <ref name="urlA Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection">{{cite web |url=https://escholarship.org/uc/item/0mj588gb |title=A Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection |format= |work= |accessdate=}}</ref>


OR
'''Urinary retention:'''


Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
* [[Foley catheter]] insertion will show and relieve [[Urinary retention|retained urine]].


OR
'''Lumbar Puncture ([[LP]]):'''


There are no diagnostic laboratory findings associated with [disease name].
* [[CSF]] analysis may show lymphocytic [[pleocytosis]] and elevated [[protein]] level. <ref name="urlAcute transverse myelitis after COVID-19 pneumonia">{{cite web |url=https://rdcu.be/b5i3c |title=Acute transverse myelitis after COVID-19 pneumonia |format= |work= |accessdate=}}</ref>
To view the laboratory findings on COVID-19, [[COVID-19 laboratory findings|click here]]


===Electrocardiogram===
===Electrocardiogram===
There are no ECG findings associated with [disease name].
OR


An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
* There are no [[ECG]] findings associated with COVID-19-associated myelitis.
* To view the electrocardiogram findings on COVID-19, [[COVID-19 electrocardiogram|click here]].<br />


===X-ray===
===X-ray===
There are no x-ray findings associated with [disease name].
OR
An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR


There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
* [[Chest X-ray]] may or may not show opacities in lungs depending on the degree of [[lung]] damage caused by COVID-19.
* To view the x-ray finidings on COVID-19, [[COVID-19 x ray|click here]].<br />


===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===
There are no echocardiography/ultrasound  findings associated with [disease name].
*There are no echocardiography findings associated with COVID-19-associated myelitis.
 
*Abdominal [[ultrasound]] may show [[bladder distension]] due to [[urinary retention]].
OR
* To view the echocardiographic findings on COVID-19, [[COVID-19 echocardiography and ultrasound|click here]].<br />
 
Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no echocardiography/ultrasound  findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===CT scan===
===CT scan===
There are no CT scan findings associated with [disease name].
OR
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR


There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
* CT scan exclude other causes that can cause myelitis.
* To view the CT scan findings on COVID-19, [[COVID-19 CT scan|click here]].


===MRI===
===MRI===
There are no MRI findings associated with [disease name].
OR
[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
===Other Imaging Findings===
There are no other imaging findings associated with [disease name].
OR
[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
===Other Diagnostic Studies===
There are no other diagnostic studies associated with [disease name].
OR
[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR


Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].
* [[MRI]] may be used to exclude other causes.
* [[MRI]] findings consistent with Acute [[Transverse Myelitis]] (involving more than three spinal cord segments) are seen.
* This includes widespread elongated signal changes throughout the [[gray matter]] of [[spinal cord]], with no disc [[pathology]] or [[spinal canal]] narrowing.
* T2-weighted fast spin-echo and short-tau inversion recovery (STIR) are the best sequences to view the [[spinal cord]] lesions<ref name="pmid11794482">{{cite journal| author=Scotti G, Gerevini S| title=Diagnosis and differential diagnosis of acute transverse myelopathy. The role of neuroradiological investigations and review of the literature. | journal=Neurol Sci | year= 2001 | volume= 22 Suppl 2 | issue=  | pages= S69-73 | pmid=11794482 | doi=10.1007/s100720100038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11794482  }} </ref>.
* To view other imaging findings on [[COVID-19]], [[COVID-19 other imaging findings|click here]].<br />


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
OR
Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
OR
The majority of cases of [disease name] are self-limited and require only supportive care.
OR
[Disease name] is a medical emergency and requires prompt treatment.
OR
The mainstay of treatment for [disease name] is [therapy].
OR
The optimal therapy for [malignancy name] depends on the stage at diagnosis.
OR
[Therapy] is recommended among all patients who develop [disease name].
OR
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
OR
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
OR
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
OR


Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
* [[Oxygen]] [[inhalation]] [[treatment]] with high-flow [[nasal]] [[catheters]].
* [[Ganciclovir]] ( 0.5g once daily) for 14 days, [[Lopinavir]]/[[ritonavir]] (500mg twice daily) for 5 days. {{cite web |url=https://www.covid19treatmentguidelines.nih.gov/ |title=Coronavirus Disease 2019 (COVID-19) Treatment Guidelines |format= |work= |accessdate=}}
* [[Moxifloxacin]] (400mg once daily) for 6 days.([[Treatment]] with [[arbidol]] and [[moxifloxacin]] could be helpful in reducing [[viral load]] and [[inflammation]] during [[SARS-CoV2]] [[infection]], especially for negatively regulating [[fatal]] [[inflammation]] in severe [[COVID-19]] patients)<ref name="YuSun2020">{{cite journal|last1=Yu|first1=Dongshan|last2=Sun|first2=Shuilin|last3=Li|first3=Yanhua|last4=Xi|first4=Wenna|last5=Jin|first5=Di|last6=Sun|first6=Ke|last7=Yu|first7=Rongyan|last8=Yao|first8=Xuebing|last9=Song|first9=Zhiying|last10=Yang|first10=Aoyu|last11=Luo|first11=Ruixia|last12=Zou|first12=Biaoshu|last13=Liu|first13=Yun|year=2020|doi=10.1101/2020.05.30.20117598}}</ref>.
* [[Glutathione]] (1.8g once daily) for 14 days. ([[Glutathione]] inhibits [[replication]] of various [[viruses]] at different stages of the [[viral]] [[life cycle]] and decreasing [[viral load]]. It also prevents the massive release of [[inflammatory]] cells into the [[lung]] “[[cytokine storm]]”)<ref name="De FloraGrassi1997">{{cite journal|last1=De Flora|first1=S.|last2=Grassi|first2=C.|last3=Carati|first3=L.|title=Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment|journal=European Respiratory Journal|volume=10|issue=7|year=1997|pages=1535–1541|issn=00000000|doi=10.1183/09031936.97.10071535}}</ref>.
* [[Dexamethasone]] (10mg once daily) for 10 days<ref name="SotocaRodríguez-Álvarez2020">{{cite journal|last1=Sotoca|first1=Javier|last2=Rodríguez-Álvarez|first2=Yensa|title=COVID-19-associated acute necrotizing myelitis|journal=Neurology - Neuroimmunology Neuroinflammation|volume=7|issue=5|year=2020|pages=e803|issn=2332-7812|doi=10.1212/NXI.0000000000000803}}</ref>. (NIH COVID-19 Treatment Guidelines Panel recommends using dexamethasone (at a dose of 6 mg per day for up to 10 days) in patients with COVID-19 who are mechanically ventilated and in patients with COVID-19 who require supplemental oxygen but who are not mechanically ventilated. And recommends against using dexamethasone in patients with COVID-19 who do not require supplemental oxygen.
* [[Human immunoglobulin]] (15g once daily) for 7 days.
* [[Pantoprazole]] (80mg once daily) for 10 days.
* [[Mecobalamin]] (1000ug once daily) for 14days.<ref name="nairnarayanan">{{cite journal|last1=nair|first1=deepak t|last2=narayanan|first2=naveen|doi=10.35543/osf.io/p48fa}}</ref> ([[Vitamin B12]] may inhibit [[RNA-dependent-RNA polymerase]] activity of [[nsp12 protein]] from the [[COVID-19]] [[Virus]]).
* Plasma exchange.
* [[Foley catheter|Foley's catheter]] to relieve [[urinary retention]]


===Surgery===
===Surgery===
Surgical intervention is not recommended for the management of [disease name].
OR
Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]
OR
The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].
OR
The feasibility of surgery depends on the stage of [malignancy] at diagnosis.
OR


Surgery is the mainstay of treatment for [disease or malignancy].
* Surgical intervention is not recommended for the management of COVID-19-associated myelitis.


===Primary Prevention===
===Primary Prevention===
There are no established measures for the primary prevention of [disease name].
OR
There are no available vaccines against [disease name].
OR
Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
OR


[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].
* Effective measures for the [[primary prevention]] of COVID-19-associated myelitis are the same as of [[COVID-19]].


===Secondary Prevention===
===Secondary Prevention===
There are no established measures for the secondary prevention of [disease name].
OR


Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].
* Effective measures for the [[secondary prevention]] of COVID-19-associated myelitis are the same as of [[COVID-19]].


==References==
==References==
{{reflist|2}}
{{reflist|2}}
[[Category:Up-To-Date]]


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Latest revision as of 23:50, 12 December 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Musadiq Ali M.B.B.S.[2] Tayebah Chaudhry[3], Fahimeh Shojaei, M.D.

Synonyms and keywords:

Overview

In the current pandemic state, COVID-19 should be considered as a differential diagnosis in a patient presenting with acute myelitis. Acute Transverse Myelitis is a neurological condition characterized by inflammation and injury of the spinal cord. In a confirmed or newly diagnosed patient of COVID-19, it is thought to be either a direct consequence of viral infection or a sequalae of autoimmune-mediated response. COVID-19-associated myelitis is diagnosed based on the hallmark symptoms of acute myelitis and confirmed with changes on spinal MRI, after ruling out other possible etiologies of myelitis. The symptoms show marked improvement after treatment with steroids and plasma exchange.

Historical Perspective

  • First case of acute myelitis as a COVID-19 complication was reported in February 2020 in Wuhan by Kang Zhao et al, in a 66 year old male patient. [1]
  • The second case was reported in Boston by Sarma et al in a 28 year old female patient who developed acute myelitis 7 days after symptoms of upper respiratory tract infection. [2]
  • As of now, only few case reports have been published in literature showing an association of COVID-19 with acute myelitis as a neurological complication.

Classification

  • There is no established system for the classification of COVID-19-associated myelitis.

Pathophysiology

Causes

Apart from COVID-19 other causes of viral myelitis include[7]:

Other causes of myelitis are:

Differentiating COVID-19-associated myelitis from other Diseases

  • For further information about the differential diagnosis, click here.
  • To view the differential diagnosis of COVID-19, click here.

Epidemiology and Demographics

  • As of now, the incidence of acute myelitis associated with Covid-19 infection in unknown. [8][9]
  • To view epidemiology and demographics for COVID-19, click here.

Risk Factors

  • There are no established risk factors for COVID-19-associated myelitis. However, since this condition is a direct consequence of infection by the novel coronavirus, risk factors for COVID-19 should be considered.
  • To view the risk factors of COVID-19, click here.

Screening

  • Screening for COVID-19-associated myelitis is not currently done.
  • To view screening for COVID-19, click here.

Natural History, Complications, and Prognosis

Natural History

  • Myelitis associated with COVID-19 is an acute condition. The first case of COVID-19 associated myelitis developed the symptoms 5 days after the onset of fever. [1]
  • The second case developed symptoms of myelitis 7 days after the upper respiratory symptoms. [2]

Complications

  • Lack of prompt recognition and management may result in lasting neurological complications (such as residual loss of sensation in lower extremities) after novel corona virus infection. [2]

Prognosis

  • Exact prognosis of COVID-19-associated myelitis is not known.
  • Marked improvement in symptoms is seen with steroids and plasma exchange.

Diagnosis

Diagnostic Study of Choice

  • Diagnosis of COVID-19-associated myelitis is based on the hallmark symptoms of acute myelitis in a known case of COVID-19 or a positive PCR nasal swab for COVID-19 in a new patient. And classic contrast-enhancing lesions on MRI spine.
  • Hallmark symptoms of acute myelitis include bilateral symmetric weakness and sensory changes in extremities, urinary retention and lower back pain.
  • Absence of visual symptoms such as eye pain or vision loss ( classically seen in Multiple Sclerosis or Neuromyelitis optica), negative immunoglobulin G auto-antibodies or oligoclonal bands, negative anti-nuclear antibody (ANA) test (very sensitive test for autoimmune diseases such as lupus), absence of other system involvement (such as skin rash, nodules, cardiac arrhythmias or arthritis seen in lupus or sarcoidosis) rule out other possible etiologies. [8]

History and Symptoms

Common symptoms

Less common symptoms

  • Paresthesias in lower extremities with possible ascension to upper extremities [2]
  • Numbness in lower extremities with possible ascension to upper extremities[2]
  • Numbness in tip of tongue [2]

Physical Examination

Vitals:

Abnormal vitals can be seen due to COVID-19 association. These include:

Abdominal exam:

Neurological exam:

Neurological findings are symmetric and more severe in lower extremities. [1] [2] [8]

Laboratory Findings

Nasal swab:

Other Viral Screening:

MRI spine:

  • MRI findings consistent with Acute Transverse Myelitis (involving more than three spinal cord segments) are seen. This includes widespread elongated signal changes throughout the gray matter of spinal cord, with no disc pathology or spinal canal narrowing. [2]

Urinary retention:

Lumbar Puncture (LP):

To view the laboratory findings on COVID-19, click here

Electrocardiogram

  • There are no ECG findings associated with COVID-19-associated myelitis.
  • To view the electrocardiogram findings on COVID-19, click here.

X-ray

  • Chest X-ray may or may not show opacities in lungs depending on the degree of lung damage caused by COVID-19.
  • To view the x-ray finidings on COVID-19, click here.

Echocardiography or Ultrasound

CT scan

  • CT scan exclude other causes that can cause myelitis.
  • To view the CT scan findings on COVID-19, click here.

MRI

Treatment

Medical Therapy

  • Oxygen inhalation treatment with high-flow nasal catheters.
  • Ganciclovir ( 0.5g once daily) for 14 days, Lopinavir/ritonavir (500mg twice daily) for 5 days. "Coronavirus Disease 2019 (COVID-19) Treatment Guidelines".
  • Moxifloxacin (400mg once daily) for 6 days.(Treatment with arbidol and moxifloxacin could be helpful in reducing viral load and inflammation during SARS-CoV2 infection, especially for negatively regulating fatal inflammation in severe COVID-19 patients)[12].
  • Glutathione (1.8g once daily) for 14 days. (Glutathione inhibits replication of various viruses at different stages of the viral life cycle and decreasing viral load. It also prevents the massive release of inflammatory cells into the lung “cytokine storm”)[13].
  • Dexamethasone (10mg once daily) for 10 days[14]. (NIH COVID-19 Treatment Guidelines Panel recommends using dexamethasone (at a dose of 6 mg per day for up to 10 days) in patients with COVID-19 who are mechanically ventilated and in patients with COVID-19 who require supplemental oxygen but who are not mechanically ventilated. And recommends against using dexamethasone in patients with COVID-19 who do not require supplemental oxygen.
  • Human immunoglobulin (15g once daily) for 7 days.
  • Pantoprazole (80mg once daily) for 10 days.
  • Mecobalamin (1000ug once daily) for 14days.[15] (Vitamin B12 may inhibit RNA-dependent-RNA polymerase activity of nsp12 protein from the COVID-19 Virus).
  • Plasma exchange.
  • Foley's catheter to relieve urinary retention

Surgery

  • Surgical intervention is not recommended for the management of COVID-19-associated myelitis.

Primary Prevention

Secondary Prevention

References

  1. ↑ 1.0 1.1 1.2 "www.medrxiv.org" (PDF).
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 "A Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection".
  3. ↑ Manji H, Carr AS, Brownlee WJ, Lunn MP (2020). "Neurology in the time of COVID-19". J Neurol Neurosurg Psychiatry. 91 (6): 568–570. doi:10.1136/jnnp-2020-323414. PMID 32312872 Check |pmid= value (help).
  4. ↑ Wan Y, Shang J, Graham R, Baric RS, Li F (2020). "Receptor Recognition by the Novel Coronavirus from Wuhan: an Analysis Based on Decade-Long Structural Studies of SARS Coronavirus". J Virol. 94 (7). doi:10.1128/JVI.00127-20. PMC 7081895 Check |pmc= value (help). PMID 31996437.
  5. ↑ Baig AM (2020). "Neurological manifestations in COVID-19 caused by SARS-CoV-2". CNS Neurosci Ther. 26 (5): 499–501. doi:10.1111/cns.13372. PMC 7163592 Check |pmc= value (help). PMID 32266761 Check |pmid= value (help).
  6. ↑ Pastor Bandeira, Isabelle; Machado Schlindwein, Marco Antônio; Breis, Leticia Caroline; Schatzmann Peron, Jean Pierre; Magno Gonçalves, Marcus Vinicius (2020). doi:10.20944/preprints202004.0304.v1. Missing or empty |title= (help)
  7. ↑ Pekcevik Y, Mitchell CH, Mealy MA, Orman G, Lee IH, Newsome SD; et al. (2016). "Differentiating neuromyelitis optica from other causes of longitudinally extensive transverse myelitis on spinal magnetic resonance imaging". Mult Scler. 22 (3): 302–11. doi:10.1177/1352458515591069. PMC 4797654. PMID 26209588.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 AlKetbi, Reem; AlNuaimi, Dana; AlMulla, Muna; AlTalai, Nouf; Samir, Mohammed; Kumar, Navin (2020). "Acute Myelitis as a Neurological Complication ofCovid-19:A Case Report and MRI Findings". Radiology Case Reports. doi:10.1016/j.radcr.2020.06.001. ISSN 1930-0433.
  9. ↑ Munz M, Wessendorf S, Koretsis G, Tewald F, Baegi R, Krämer S; et al. (2020). "Acute transverse myelitis after COVID-19 pneumonia". J Neurol. doi:10.1007/s00415-020-09934-w. PMC 7250275 Check |pmc= value (help). PMID 32458198 Check |pmid= value (help).
  10. ↑ "Acute transverse myelitis after COVID-19 pneumonia".
  11. ↑ Scotti G, Gerevini S (2001). "Diagnosis and differential diagnosis of acute transverse myelopathy. The role of neuroradiological investigations and review of the literature". Neurol Sci. 22 Suppl 2: S69–73. doi:10.1007/s100720100038. PMID 11794482.
  12. ↑ Yu, Dongshan; Sun, Shuilin; Li, Yanhua; Xi, Wenna; Jin, Di; Sun, Ke; Yu, Rongyan; Yao, Xuebing; Song, Zhiying; Yang, Aoyu; Luo, Ruixia; Zou, Biaoshu; Liu, Yun (2020). doi:10.1101/2020.05.30.20117598. Missing or empty |title= (help)
  13. ↑ De Flora, S.; Grassi, C.; Carati, L. (1997). "Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment". European Respiratory Journal. 10 (7): 1535–1541. doi:10.1183/09031936.97.10071535. ISSN 0000-0000.
  14. ↑ Sotoca, Javier; Rodríguez-Álvarez, Yensa (2020). "COVID-19-associated acute necrotizing myelitis". Neurology - Neuroimmunology Neuroinflammation. 7 (5): e803. doi:10.1212/NXI.0000000000000803. ISSN 2332-7812.
  15. ↑ nair, deepak t; narayanan, naveen. doi:10.35543/osf.io/p48fa. Missing or empty |title= (help)


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