COVID-19-associated myelitis: Difference between revisions

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{{SI}}
{{SI}}


{{CMG}}; {{AE}} {{sali}} [[User:Tayebah Chaudhry|Tayebah Chaudhry]][mailto:dr.thch@yahoo.com]
{{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.
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]].
 
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/or [[plasma exchange]].


==Historical Perspective==
==Historical Perspective==
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* 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>
* 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>
* 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, few case reports have been published in literature showing an association of COVID-19 with acute myelitis as a neurological complication.
*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==
==Classification==
There is no established system for the classification of COVID-19-associated myelitis.
 
* There is no established system for the classification of COVID-19-associated myelitis.


==Pathophysiology==
==Pathophysiology==


*The pathogenesis of the disease behind this manifestation is not fully understood yet.  
*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 enzyme2 (ACE2) as its receptor to interact with host cells.  
*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 receptors 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.
*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 receptors are expressed on alveolar epithelial cells, intestinal enterocytes and arterial and venous endothelial cells.
*The [[ACE2 receptor]]s are expressed on [[alveolar epithelial cell]]s, [[intestinal enterocytes]] and [[arterial]] and [[venous]] [[endothelial cell]]s.
*The brain only the vascular cells were expressing ACE2 as a cell receptor not the neurons; yet this could be a potential mechanism for dissemination of the virus into the brain by the blood circulation.
*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.  
*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>.
*This route must be taken into consideration in cases of early‐phase COVID‐19‐affected patients who exhibit loss of smell and taste.  
*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>.
*Furthermore, in advanced stages of the disease the neurological signs and symptoms observed in the COVID‐19 cases could be due to the effects of hypoxia, respiratory, and metabolic acidosis
*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==
==Causes==


* Apart from Covid associated Myelitis other Viruses associated with myelitis are:
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]]


*Herpes viruses, including the one that causes shingles and chickenpox (zoster)
Other causes of myelitis are:
*Cytomegalovirus
*[[Bacterial myelitis]]
*Epstein-Barr
*[[Fungal myelitis]]
*HIV
*[[Parasitic myelitis]]
*Enteroviruses such as poliovirus and coxsackievirus
*[[Multiple Sclerosis]]
*West Nile
*[[Transverse Myelitis]]
*Echovirus
*[[Autoimmune]] disorders like [[SLE]] and [[Sjogren’s Syndrome]]
*Zika
*[[Sarcoidosis]]
*Influenza
*[[Vaccinations]]
*Hepatitis B
*Mumps, measles and rubella


==Differentiating COVID-19-associated myelitis from other Diseases==
==Differentiating COVID-19-associated myelitis from other Diseases==


*There are a number of conditions that appear to cause myelitis and hence should be differentiated from COVID-19-associated myelitis:
*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]].
===Multiple sclerosis===
 
*The immune system destroys myelin surrounding nerves in your spinal cord and brain. Transverse myelitis can be the first sign of multiple sclerosis or represent a relapse. Transverse myelitis as a sign of multiple sclerosis usually causes symptoms on only one side of your body. Neuromyelitis optica (Devic's disease) is a condition that causes inflammation and myelin loss around the spinal cord and the nerve in your eye that transmits information to your brain. Transverse myelitis associated with neuromyelitis optica usually affects both sides of your body.
 
===Transverse myelitis===
 
* Transverse myelitis experience symptoms of damage to myelin of the optic nerve, including pain in the eye with movement and temporary vision loss. This can happen with or separately from transverse myelitis symptoms. However, some people with neuromyelitis optica don't experience eye-related problems and might have only recurrent episodes of transverse myelitis.
 
===Autoimmune disorders===
* These disorders include lupus, which can affect multiple body systems, and Sjogren's syndrome, which causes severe dryness of the mouth and eyes.
 
===Vaccinations===
* Vaccination for infectious diseases have occasionally been associated as a possible trigger. However, at this time the association is not strong enough to warrant limiting any vaccine.
 
===Sarcoidosis===
* Sarcoidosis is a condition that leads to inflammation in many areas of the body, including the spinal cord and optic nerve. It may mimic neuromyelitis optica, but typically sarcoidosis symptoms develop more slowly. The cause of sarcoidosis isn't understood.


==Epidemiology and Demographics==
==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>
* 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==
==Risk Factors==
There are no established risk factors for COVID-19-associated myelitis.
 
* 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==


Screening for COVID-19-associated myelitis is not currently done.
* 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, 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.  
*Exact prognosis of COVID-19-associated myelitis is not known.  
*Marked improvement in symptoms is seen with steroids and plasma exchange. However, lack of prompt recognition and management may result in lasting neurological effects (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>
*Marked improvement in symptoms is seen with steroids and plasma exchange.


==Diagnosis==
==Diagnosis==
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===History and Symptoms===
===History and Symptoms===
Symptoms of [[COVID-19-associated myelitis]] include:
'''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>
*[[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>


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* 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>
* 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>
* 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>
* [[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 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>
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===Physical Examination===
===Physical Examination===




'''Vitals:'''
'''Vitals:'''


Abnormal vitals can be seen due to COVID-19 association. These include:
Abnormal vitals can be seen due to [[COVID-19]] association. These include:
*Decreased O2 saturation
*Decreased O2 saturation
*[[Tachycardia]]
*[[Tachycardia]]
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'''Abdominal exam:'''
'''Abdominal exam:'''
*Palpable distended urinary bladder
*Palpable [[Bladder distension|distended bladder]]


'''Neurological exam:'''
'''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>
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="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>
<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
*Wide based [[gait]]
*Decreased muscle strength
*Decreased muscle strength
*Decreased sensation
*Decreased sensation
*Decreased [[proprioception]]
*Decreased [[proprioception]]
*Hyporeflexia
*[[Hyporeflexia]]
*[[Paresthesias]]
*[[Paresthesias]]
*Positive [[Lhermitte's sign]]
*Positive [[Lhermitte's sign]]
*Positive Babinski's sign bilaterally.
*Positive [[Babinski's sign]] bilaterally.


===Laboratory Findings===
===Laboratory Findings===
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'''Nasal swab:'''
'''Nasal swab:'''


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


'''Other Viral Screening:'''
'''Other Viral Screening:'''
*Viral PCR screening including [[Adenovirus]], [[Herpes Simplex Virus]] (Type 1&2), [[Epstein Barr]] Virus, [[Cytomegalovirus]], [[Human Immunodeficiency Virus]] ([[HIV]]) will yield negative results.
*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.
*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]].
*Negative antibody results for bacteria such as [[Chlamydia]] Pneumoniae, [[Bordetella]] Pertussis, [[Mycoplasma]] Pneumoniae and [[Borrelia]].
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'''MRI spine:'''
'''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. <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>
* [[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:'''
'''Urinary retention:'''


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


'''Lumbar Puncture ([[LP]]):'''
'''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>
 
* [[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 COVID-19-associated myelitis.
 
* 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===
Chest X-ray may or may not show opacities in lungs depending on the degree of lung damage caused by COVID-19.
 
* [[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 findings associated with COVID-19-associated myelitis.
*There are no echocardiography findings associated with COVID-19-associated myelitis.
*Abdominal ultrasound may show bladder distention due to urinary retention.
*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===


CT chest may show patchy changes in the lung fields due to COVID-19-associated lung damage.
* 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===


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.
* [[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===


*Steroids (such as [[prednisolone]], [[dexamethasone]])
* [[Oxygen]] [[inhalation]] [[treatment]] with high-flow [[nasal]] [[catheters]].
*[[plasma exchange]]
* [[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=}}
*[[Foley's catheter]] to relieve urinary retention
* [[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.
* Surgical intervention is not recommended for the management of COVID-19-associated myelitis.
 
OR
 
Surgery is the mainstay of treatment for [disease or malignancy].


===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 COVID-19-associated myelitis are the same as of [[COVID-19]].
 
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].


===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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