View source for COVID-19-associated myelitis

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{{SI}}

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

{{SK}} 

==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. <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>
*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==

*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. 
*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.
*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>.
*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>.

==Causes==

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>:

*[[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]]

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==

*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==

* 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 />

==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, [[COVID-19 risk factors|click here]].

==Screening==

* Screening for COVID-19-associated myelitis is not currently done.
* To view screening for COVID-19, [[COVID-19 screening|click here]].<br />

==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. <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>

'''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'''
*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. <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===
'''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>

*[[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>

'''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===



'''Vitals:'''

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

'''Abdominal exam:'''
*Palpable [[Bladder distension|distended bladder]]

'''Neurological exam:'''

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===

'''Nasal swab:'''

* [[PCR]] nasal swab may give positive result for [[COVID-19]].

'''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]].

'''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 [[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>

'''Urinary retention:'''

* [[Foley catheter]] insertion will show and relieve [[Urinary retention|retained urine]].

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

* [[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===

* 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===

* [[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===
*There are no echocardiography findings associated with COVID-19-associated myelitis.
*Abdominal [[ultrasound]] may show [[bladder distension]] due to [[urinary retention]].
* To view the echocardiographic findings on COVID-19, [[COVID-19 echocardiography and ultrasound|click here]].<br />

===CT scan===

* 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]] 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==
===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. {{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===

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

===Primary Prevention===

* Effective measures for the [[primary prevention]] of COVID-19-associated myelitis are the same as of [[COVID-19]].

===Secondary Prevention===

* Effective measures for the [[secondary prevention]] of COVID-19-associated myelitis are the same as of [[COVID-19]].

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

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