COVID-19-associated acute necrotizing myelitis

Myelin oligodendrocyte glycoprotein-associated transverse myelitis after SARS-CoV-2 infection: A case report

BACKGROUND

Cases of myelin oligodendrocyte glycoprotein (MOG) antibody-related disease have a history of coronavirus disease 2019 infection or its vaccination before disease onset. Severe acute respiratory syndrome virus 2 (SARS-CoV-2) infection has been considered to be a trigger of central nervous system autoimmune diseases.

CASE SUMMARY

Here we report a 20-year male with MOG-associated transverse myelitis after a SARS-CoV-2 infection. The patient received a near-complete recovery after standard immunological treatments.

CONCLUSION

Attention should be paid to the evaluation of typical or atypical neurological symptoms that may be triggered by SARS-CoV-2 infection.

Plasmapheresis in post-COVID-19 myelitis: A case report

BACKGROUND

Previous studies have delineated different neurological manifestations associated with coronavirus disease 2019 (COVID-19). Myelitis is identified as a rare neurological complication resulting from a COVID-19 infection. Limited information is available regarding the treatment of patients experiencing this condition.

CASE REPORT

This report extracts data from the medical record of a post-COVID-19 myelitis patient at Buriram Hospital and follows up prospectively on the patient's symptoms after treatment. A 61-year-old man, previously vaccinated for COVID-19 and with a history of hypertension and dyslipidemia, experienced progressive bilateral lower-extremity weakness (recorded as muscle strength grade 2/5 in both lower extremities) for 6 weeks. He had a mild case of COVID-19 2 months earlier, which resolved in 10 days without specific treatment. However, 2 weeks after being diagnosed with COVID-19, he developed weakness in his lower limbs, numbness below the nipple, and urinary retention. Spinal magnetic resonance imaging revealed multifocal longitudinal myelitis. Despite initial treatment with methylprednisolone, the patient showed no clinical improvement. Consequently, he underwent five cycles of plasmapheresis. Three months after discharge, a notable improvement was observed, with his muscle strength graded at 4/5 in both lower extremities and the resolution of sensory and urinary symptoms.

CONCLUSIONS

We presented the case of a COVID-19-vaccinated patient, in whom COVID-19 infection might have led to myelitis. We found promising results in treating prolonged COVID-19-related myelitis symptoms through the use of plasmapheresis.

Treatment refractory acute necrotizing myelitis after COVID-19 vaccine injection: a case report

Introduction and importance

Post-vaccination myelitis is a rare and debilitating clinical situation. There are few reports of post-COVID-19 infection and vaccination neurological sequela.

Case presentation

A 69-year-old lady was admitted to the emergency department due to weakness and hypoesthesia in her hands 1 week after the Sinopharm vaccine injection. MRI showed a cervicothoracic cord haemorrhagic lesion that deteriorated within 48 h. The clinical course was refractory to conservative treatments. She underwent an emergency cervical laminectomy as a salvage treatment. Intraoperative samples were in favour of acute necrotizing myelitis.

Discussion

In the review of the literature, the inflammatory storm, vasculitis, and many unknown etiologies are deemed to be the possible causes of encephalopathy and myelitis after COVID-19 infection and vaccination. There are few cases of post-COVID-19 myelitis and hematomyelia, but this case was the first report of post-vaccination necrotizing myelitis.

Conclusion

Post-vaccination necrotizing myelitis is a lethal medical situation requiring intensive and emergent neurosurgical vigilance. Early clinical diagnosis in the beginning and full neurosurgical-neurological treatment armamentarium options are cornerstones of treatment paradigms. Salvage treatment options such as extensive laminectomy may play a life-saving role in treatment refractory cases of acute necrotizing myelitis.

Acute Necrotizing Myelitis Associated with COVID-19

Acute ascending hemorrhagic longitudinally extensive transverse myelitis is a rare inflammatory demyelinating disorder, which invades several vertebral segments and progresses rapidly and manifests severe symptoms. We present a case of acute necrotizing myelitis associated with COVID-19 infection. A 10-year-old female, with no previous medical history and no prior administration of COVID-19 vaccination, contracted COVID-19 in early April 2022. Two weeks later, she suffered from severe posterior neck pain and also presented with motor weakness and numbness in both lower extremities, making it difficult to walk independently and spontaneously void urine. Initial spinal cord MR showed longitudinally segmental extensive T2 hyperintensities. Cerebrospinal fluid (CSF) analysis revealed elevated red blood cell, normal white blood cell, and elevated protein levels and absence of oligoclonal bands. CSF culture and viral polymerase chain reaction were negative. Autoimmune work-up was negative. She was started on intravenous methylprednisolone 1g/day for 5 days and immunoglobulin (Ig) 2 g/kg for 5 days. She was also treated with six courses of therapeutic plasma exchange. Nevertheless, her pain and motor weakness persisted. She eventually developed respiratory failure. Follow-up MR presented a newly noted small hemorrhagic component. She was consequently treated with two additional courses of methylprednisolone and Ig. At 6-months follow-up, neurological examination showed improvement with normal sensory function and motor grade IV function in both upper extremities. We present the case of acute necrotizing myelitis associated with COVID-19 infection. Multiple courses of methylprednisolone and Ig showed mild improvement in motor and sensory function. However, poor prognosis was unavoidable due to rapid progression of the disease.

Pearls & Oy-sters: Hemorrhagic Myelitis Following SARS-CoV-2 Infection

Hemorrhage in the setting of myelitis is rarely seen in clinical practice. We report a series of 3 women aged 26, 43, and 44 years, who presented with acute hemorrhagic myelitis within 4 weeks of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Two required intensive care, and 1 had severe disease with multiorgan failure. Serial MRI of the spine demonstrated T2-weighted hyperintensity with T1-weighted postcontrast enhancement in the medulla and cervical spine (patient 1) and thoracic spine (patients 2 and 3). Hemorrhage was identified on precontrast T1-weighted, susceptibility-weighted, and gradient echo sequences. Distinct from typical inflammatory or demyelinating myelitis, clinical recovery was poor in all cases, with residual quadriplegia or paraplegia, despite immunosuppression. These cases highlight that although hemorrhagic myelitis is rare, it can occur as a post/parainfectious complication of SARS-CoV-2 infection.

Covid-19 vaccines and neurological complications: a systematic review

The COVID-19 mainly causes respiratory disorders with high infection and severe morbidity and mortality. Neurologists have concerns about potential neurological side effects, profits, and timing of COVID-19 vaccines. This study aimed to review systematically research for the COVID-19 vaccine and neurological complications. Data was searched in Scopus, ISI web of knowledge, Medline, PubMed, Wiley, Embase, International Clinical Trials Registry Platform and Clinical Trials, Cochrane Library, and Google Scholar. Two reviewer authors individually searched and assessed the titles and abstracts of all articles. The third reviewer resolved disagreement between them. Data were documented regarding study location, study design, type of complications, number of patients, various types of COVID-19 vaccine, and type of neurological complications. Six studies in COVID-19 vaccine and neurological complications include two studies about neurological manifestations after the mRNA vaccines, four records about side effects of vector-based vaccine were included in the study. The main neurological complication associated mRNA vaccines were body aches, paresthesia, and difficulty walking, erythema migrans lesion, fatigue, myalgia, and pain in the left lateral deltoid region. The major neurological complication related to vector-based vaccines were urinary retention difficulty, feeding and ambulating, arm soreness, mild fatigue, chills, left-sided facial droop, headaches, a generalized epileptic seizure, hemianopia, and mild aphasia, acute somnolence and right-hand hemiparesis, acute transverse myelitis, deep vein thrombosis in her left leg, a vigilance disorder and a twitching, a severe immobilizing opsoclonus myoclonus syndrome, and encephalitis. A large spectrum of severe neurological unfavorable has been reported. These complications could occur as a result of molecular stimulation and later neuronal damage. Generally, the advantages of COVID-19 vaccination are dominant on the risks of a neurological complication at both individual and population levels. Future investigations will be required to find any relationship between neurological complications and COVID-19 vaccines principally as new strains of the virus and new vaccines are technologically advanced against them.

Transverse myelitis following COVID-19: Insights from a multi-center study and systematic literature review

INTRODUCTION

We aimed to provide insights into transverse myelitis (TM) following COVID-19 by analyzing cases treated at tertiary care neurology centers and a systemic review of the literature.

METHODS

The retrospective observational multi-center study was conducted at the four university neurology departments in Croatia, Slovenia, Serbia, and Austria. We searched for acute myelitis cases that occurred during or after COVID-19. A systemic review of the literature on COVID-19 and transverse myelitis was performed.

RESULTS

We identified 76 persons with TM associated with COVID-19, 13 from the multi-center study and 63 from the literature review. Most of the participants (55.6%) had an intermediate latency, 25.4% had short and 19% long latency from COVID-19 symptoms to TM. The clinical presentation consisted of the typical TM signs. More than half of the participants had inflammatory changes in the CSF, with rare patients having intrathecal OCB synthesis and positive serology for anti-MOG or anti-AQP4 antibodies. Persons with autonomic symptoms and CSF pleocytosis were significantly more common to have an intermediate latency of 8 to 21 days from COVID-19 to TM (p = 0.005 and p = 0.003; respectively). According to logistic regression analysis, only participants with lesions evident on spinal cord MRI compared to normal spinal cord MRI had reduced risks for poor recovery. >80% of participants were treated with a combination of corticosteroids and intravenous immunoglobulins or plasma exchange with 73% having incomplete recovery.

CONCLUSION

Our study further characterizes clinical, laboratory, and MRI features, as well as treatment of TM associated with COVID-19.

Acute cerebellitis, transverse myelitis and polyradiculoneuritis related to post-COVID-19 infection

CONTEXT

Guillain-Barré syndrome (GBS), acute cerebellitis and transverse myelitis are rare complications of COVID-19 infection separately. The combination of these three, however, has not yet been reported.

FINDINGS

We present an atypical case (42-year-old man) that developed acute ascending flaccid paraparesis, ataxia and urinary retention two weeks after COVID-19 infection. Neurological examination revealed distal and proximal weakness (4/5) on lower extremities, decreased tendon reflexes, sixth cranial nerve palsy and dysmetria without sensory disturbance. His cranial MRI showed cerebellitis whereas the spinal MRI showed transverse myelitis at the T11/12 level. Albuminocytologic dissociation was present in the cerebrospinal fluid. The nerve conduction study was concordant with early findings of GBS. He recovered well after corticosteroid treatment without needing any immunotherapy. On day seven of hospitalization, the modified Rankin Scale score was 0.

CONCLUSION

COVID-19 infection may present with a combination of neurological manifestations such as cerebellitis, transverse myelitis and GBS. This patient presented significant functional recovery after treatment with corticosteroid without immunotherapy.

Imaging of Common Spinal Cord Diseases

Spinal cord evaluation is an integral part of spine assessment, and its reliable imaging work-up is mandatory because even localized lesions may produce serious effects with potentially irreversible sequelae. Spinal cord alterations are found both incidentally during spine evaluation in otherwise neurologically asymptomatic patients or during neurologic/neuroradiologic assessment in myelopathic patients. Myelopathy (an umbrella term for any neurologic deficit that refers to spinal cord impairment) can be caused by intrinsic lesions or extrinsic mechanical compression, and its etiology may be both traumatic and/or nontraumatic. The symptoms largely depend on the size/extension of lesions, ranging from incontinence to ataxia, from spasticity to hyperreflexia, from numbness to weakness. Magnetic resonance imaging is the reference imaging modality in spinal cord evaluation, ensuring the best signal and spatial resolution. We provide an overview of the most common spinal cord disorders encountered by radiologists and describe the technical measures that offer optimal spinal cord visualization.

Acute Ascending Necrotizing Myelitis Following COVID-19 Infection: A Clinicopathological Report

Background and Objectives:

Neurological manifestations of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS CoV-2, COVID-19) infection are common and varied. The objective of this report is to describe clinicopathological findings of rare acute ascending necrotizing myelitis (ANM) and briefly summarize similar COVID-19-associated longitudinally extended transverse myelitis (LETM) cases.

Methods:

We describe the clinical presentation, disease course, diagnostic workup, therapeutic measures, and pathological findings of ANM associated with COVID-19 infection.

Results:

A 31-year-old previously healthy woman developed a longitudinally extensive lower thoracic myelopathy three weeks after COVID-19 infection. The thoracic spinal cord lesion extended to cervical level in one week and then to the lower medullary level in two more weeks. Thoracic laminectomy at T5 – T6 level and cord biopsy revealed necrobiotic changes without viral particles or microglial nodules. The clinical deficit stabilized following immunomodulatory and eculizumab therapy.

Conclusion:

COVID-19 infection can cause ascending necrotizing myelitis. It adds to the spectrum of reported cases of COVID-19-associated encephalitis and myelitis.

Toxicity of spike fragments SARS-CoV-2 S protein for zebrafish: A tool to study its hazardous for human health?

Despite the significant increase in the generation of SARS-CoV-2 contaminated domestic and hospital wastewater, little is known about the ecotoxicological effects of the virus or its structural components in freshwater vertebrates. In this context, this study evaluated the deleterious effects caused by SARS-CoV-2 Spike protein on the health of Danio rerio, zebrafish. We demonstrated, for the first time, that zebrafish injected with fragment 16 to 165 (rSpike), which corresponds to the N-terminal portion of the protein, presented mortalities and adverse effects on liver, kidney, ovary and brain tissues. The conserved genetic homology between zebrafish and humans might be one of the reasons for the intense toxic effects followed inflammatory reaction from the immune system of zebrafish to rSpike which provoked damage to organs in a similar pattern as happen in severe cases of COVID-19 in humans, and, resulted in 78,6% of survival rate in female adults during the first seven days. The application of spike protein in zebrafish was highly toxic that is suitable for future studies to gather valuable information about ecotoxicological impacts, as well as vaccine responses and therapeutic approaches in human medicine. Therefore, besides representing an important tool to assess the harmful effects of SARS-CoV-2 in the aquatic environment, we present the zebrafish as an animal model for translational COVID-19 research.

Post COVID-19 Complications, Adjunct Therapy Explored, And Steroidal After Effects

For survivors of the COVID-19 disease, defeating the virus is just the beginning of a long road to recovery. The virus’s inducibility and catastrophic effects are distributed in multiple organs. The induction of cytokine storms in COVID-19 patients is due to the interaction of the SARS-CoV-2 virus and the host receptor, leading to various immunopathological consequences that might eventually lead to death. So far, it has hit tons of people across the world, but there is still no effective treatment. Patients facing the complications of COVID-19 after recovering have shown extensive clinical symptoms similar to previously circulating coronaviruses. Previous knowledge, and literature have opened up ways to treat this disease and manage post-COVID-19 complications, which poses a severe challenge to health system globally and may exacerbate the fragmentation of diseases. The use of steroids, as a treatment, showed various health problems and side-effects in COVID-19 patients. This review substantially discusses various post-COVID-19 complications observed, adjunctive therapies used along with common COVID-19treatment and spotlighted their side effects and consequences. This review provides latest literature on COVID-19 which emphasizes the subsequent complications in various organs, side-effects of drug, and alternative regimes that were used to treat COVID-19.

Central Nervous System Lesions in COVID-19

This review discusses current data on CNS lesions in infections with the new coronavirus that causes COVID-19. The pathogenetic mechanisms leading to infection of the brain and spinal cord are presented. Published studies and meta-analyses published by autumn 2020 are assessed. The authors present results from their own clinical observations of various types of CNS infection in COVID-19 virus disease. Particular attention is paid to certain common forms of CNS lesion such as encephalitis, cerebrovascular pathology, and headache. A form of acute hemorrhagic necrotic encephalopathy is identified, which is a quite rare but fatal pathology comorbid with COVID-19. A description of our own clinical observation of acute necrotic encephalopathy is presented. The importance of further studies of the effects of the coronavirus on the CNS and possible approaches to treatment and rehabilitation of this category of patients is emphasized.

New-onset neuromyelitis optica spectrum disorder in a patient with COVID-19 and chronic Hepatitis B co-infection

Background

Neurological autoimmune disorders are often triggered by bacterial and viral infections, with growing evidence supporting coronavirus disease 2019 (COVID-19) infection precipitation of these disorders. COVID-19 is already implicated in causing discrete para-infectious neurological syndromes: acute disseminated encephalomyelitis (ADEM), transverse myelitis, neuromyelitis optica spectrum disorders (NMOSD), Guillain-Barré syndrome (GBS), and is also associated with encephalopathy, acute cerebrovascular disease, neuromuscular disorders, and seizures.

Case Presentation

We describe a case of a 43-year-old Asian woman with chronic Hepatitis B (HBV) co-infected acutely with COVID-19, presenting with urinary retention, bilateral blindness, thoracic sensory level, and quadriparesis. Extensive workup narrowed down her diagnosis as seronegative NMOSD. She had complete resolution of symptoms after treatment with concurrent plasma exchange (PLEX), high dose corticosteroids, and emtricitabine-tenofovir. Follow-up visit showed no seroconversion at 6 months and no relapses.

Conclusions

Our literature review highlights the likely link between COVID-19 infection and the development of neurologic autoimmune diseases. Our literature review supports a virus-triggered immune-mediated process rather than neuro-invasion. Many viral illnesses have been linked to the development of NMOSD and anti-AQP4 antibody-related myelitis. Additionally, there is limited literature linking chronic HBV infection with the development of optic neuritis and speculation thatcross-reactivity between HBsAg and myelin antigens may lead to the development of demyelinating diseases in the CNS and PNS. We observed remarkable clinical improvement after treatment with alternating days of IV methylprednisolone and therapeutic PLEX.

Hypercoagulable State Induced Spinal Cord Stroke After Coronavirus Disease 19 Infection

Background

Spinal cord stroke after coronavirus disease 19 (COVID-19) infection is rare, and limited cases have been reported. Spinal cord ischemia after COVID-19 infection is related to increased coagulopathy with thromboembolic consequences. Patients with COVID-19 may have a hypercoagulable state and an increased rate of thromboembolic events, such as occlusion in the spinal artery.

Case Presentation

We report a male case with confirmed COVID-19 infection, aged 60 years, with flaccid paraplegia, hyporeflexia, loss of sensation below the 12th thoracic level, loss of autonomic function, bilateral positive Babinski sign 14 days after the onset of flu-like symptoms, and elevated serum D-dimer and fibrinogen levels. There was stenosis of the spinal artery at the 12th thoracic level in magnetic resonance imaging and magnetic resonance angiography. He showed improvement in motor strength of the lower limb (walking with assistance), numbness and pain, and urine and fecal retention after receiving a subcutaneous anticoagulant.

Conclusion

COVID-19 can damage endothelial cells and activate thrombotic pathways, which can lead to clinical thromboembolic complications, such as occlusion in the spinal artery, resulting in spinal cord stroke.

SARS-CoV-2-Associated Cerebrovascular Disease Amid the COVID-19 Pandemic: A Systematic Review

Background

Cerebrovascular diseases associated with SARS-CoV-2 are being increasingly reported in the literature as the coronavirus disease 2019 (COVID-19) pandemic continues. However, a case-based retrospective analysis of the literature about SARS-CoV-2-cerebrovascular disease (SCVD) is not yet well established. Thus, we reviewed the literature on SCVD covering a comprehensive range of topics spanning the clinical features, mechanism, treatment, and outcomes of patients with SCVD.

Methods

We searched PubMed^® and included single-case reports and case series with full text in English that reported original data of patients with CVD and a confirmed recent SARS-CoV-2 infection. Clinical data were extracted.

Results

We included all 51 articles indexed in PubMed^® that were published between January 1, 2020, and June 20, 2020. The selected studies reported a total of 167 cerebrovascular events including ischemic stroke, cerebral hemorrhage, subarachnoid hemorrhage, and cerebral venous thrombosis in patients with confirmed COVID-19. The detailed demographic and clinical characteristics of patients with CVD are summarized.

Conclusion

This summary of patient characteristics may help clinicians better anticipate SCVD outcomes and complications in their COVID-19 patients.

Transverse myelitis after SARS-CoV-2 infection: Report of two cases with COVID-19

Transverse myelitis has been reported as a complication of COVID-19 in recent studies. Here, we report two cases of transverse myelitis related to COVID-19. Both patients underwent plasma exchange after being treated with antibiotics and corticosteroids which lead to the recovery of one of them.

Post-COVID-19 longitudinally extensive transverse myelitis: is it a new entity?

Introduction

To the best of our knowledge, here we present two post-COVID19 longitudinally extensive transverse myelitis (LETM) with atypical presentations

Case presentations

A 44-year-old male who did not have any previous medical condition and a 73-year-old male foreigner who did not have any disease other than type 2 diabetes mellitus were admitted to our neurology clinic in the same period with similar clinical presentations of transverse myelitis. Upon admission, paraplegia and urinary-fecal incontinence were observed in their neurological examination. Neurological complaints had started within approximately 3–4 weeks following the resolution of the COVID-19 infection. Thoracic lower segment LETM was observed on spinal magnetic resonance imaging (MRI) in one of the patients, and long segment myelitis extending from the lower thoracic segment to the conus medullaris was observed in the other one. No significant diagnostic positivity was present in their diagnostic evaluation. In both cases, we assume a post-infectious etiology in terms of secondary immunogenic overreaction following COVID-19.

Conclusion

Our patients improved with multiple treatments such as methylprednisolone, intravenous immunoglobulin, and plasmapheresis. Whether post-infectious myelitis behaves differently from other viral infections after COVID-19 is currently unclear. Long lag times appear to be a post-infectious neurological complication resulting from the host response to the virus.

Molecular Mechanisms of SARS-CoV-2/COVID-19 Pathogenicity on the Central Nervous System: Bridging Experimental Probes to Clinical Evidence and Therapeutic Interventions

The coronavirus disease 2019 (COVID-19) pandemic, induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has dramatically impacted the global healthcare systems, constantly challenging both research and clinical practice. Although it was initially believed that the SARS-CoV-2 infection is limited merely to the respiratory system, emerging evidence indicates that COVID-19 affects multiple other systems including the central nervous system (CNS). Furthermore, most of the published clinical studies indicate that the confirmed CNS inflammatory manifestations in COVID-19 patients are meningitis, encephalitis, acute necrotizing encephalopathy, acute transverse myelitis, and acute disseminated encephalomyelitis. In addition, the neuroinflammation along with accelerated neurosenescence and susceptible genetic signatures in COVID-19 patients might prime the CNS to neurodegeneration and precipitate the occurrence of neurodegenerative diseases, including Alzheimer's and Parkinson's diseases. Thus, this review provides a critical evaluation and interpretive analysis of existing published preclinical as well as clinical studies on the key molecular mechanisms modulating neuroinflammation and neurodegeneration induced by the SARS-CoV-2. In addition, the essential age- and gender-dependent impacts of SARS-CoV-2 on the CNS of COVID-19 patients are also discussed.

Impact of Covid-19 on the therapeutic plasma exchange service within the South East Asian region: Consensus recommendations and global perspectives

Introduction

Therapeutic plasma exchange (TPE) for neuroimmunological disorders has played an increasingly important role within the Southeast Asian (SEA) region. The South East Asian Therapeutic Plasma exchange Consortium (SEATPEC) was formed in 2018 to promote education and research on TPE within the region. The advent of the Covid‐19 pandemic has produced challenges for the development and expansion of this service.

Methodology

A qualitative and semi‐quantitative questionnaire‐based survey was conducted by SEATPEC member countries from January to June 2020 (Phase 1) and then from July 2020 to January 2021 in (Phase 2) to assess the impact of Covid‐19 on regional TPE.

Objectives

The study's main objectives were to explore the challenges experienced and adaptations/adjustments taken by SEATPEC countries in order to continue safe and efficient TPE during the Covid‐19 pandemic.

Results

The pandemic was found to disrupt the delivery of TPE services in all SEATPEC countries. Contributing factors were multifactorial due to overstretched medical services, staff shortages, quarantines and redeployments, fear of acquiring Covid‐19, movement restriction orders, and patient's psychological fear of attending hospitals/testing for Covid‐19. All SEATPEC countries practiced careful stratification of cases for TPE (electives vs emergencies, Covid‐19 vs non‐Covid‐19 cases). SEATPEC countries had to modify TPE treatment protocols to include careful preprocedure screening of patient's for Covid‐19, use of personal protective equipment (PPE) and post‐TPE sanitization of machines and TPE suites.

Conclusion

Based on the responses of the survey, SEATPEC countries produced a consensus statement with five recommendations for safe and effective TPE within the region.

Relevance of CSF, Serum and Neuroimaging Markers in CNS and PNS Manifestation in COVID-19: A Systematic Review of Case Report and Case Series

BACKGROUND

The data on neurological manifestations in COVID-19 patients has been rapidly increasing throughout the pandemic. However, data on CNS and PNS inflammatory disorders in COVID-19 with respect to CSF, serum and neuroimaging markers is still lacking.

METHODS

We screened all articles resulting from a search of PubMed, Google Scholar and Scopus, using the keywords "SARS-CoV-2 and neurological complication", "SARS-CoV-2 and CNS Complication" and "SARS-CoV-2 and PNS Complication" looking for transverse myelitis, vasculitis, acute disseminated encephalomyelitis, acute hemorrhagic necrotizing encephalitis (AHNE), cytotoxic lesion of the corpus callosum (CLOCC) and Guillain-Barré syndrome (GBS), published between 1 December 2019 to 15 July 2021.

RESULTS

Of the included 106 CNS manifestations in our study, CNS inflammatory disorders included transverse myelitis (17, 14.7%), AHNE (12, 10.4%), ADEM (11, 9.5%), CLOCC/MERS (10, 8.6%) and vasculitis (4, 3.4%). Others were nonspecific encephalopathy, encephalitis, seizures and stroke. Most patients were >50 years old (75, 70.8%) and male (64, 65.3%). Most (59, 63.4%) were severe cases of COVID-19 and 18 (18%) patients died. Of the included 94 PNS manifestations in our study, GBS (89, 92.7%) was the most common. Most of these patients were >50 years old (73, 77.7%) and male (59, 64.1%). Most (62, 67.4%) were non-severe cases of COVID-19, and ten patients died.

CONCLUSION

Our comprehensive review of the clinical and paraclinical findings in CNS and PNS manifestations of COVID-19 provide insights on the pathophysiology of SARS-CoV-2 and its neurotropism. The higher frequency and severity of CNS manifestations should be noted by physicians for increased vigilance in particular COVID-19 cases.

Evaluation and Management of Acute Myelopathy

Acute myelopathies are spinal cord disorders characterized by a rapidly progressive course reaching nadir within hours to a few weeks that may result in severe disability. The multitude of underlying etiologies, complexities in confirming the diagnosis, and often unforgiving nature of spinal cord damage have always represented a challenge. Moreover, certain slowly progressive myelopathies may present acutely or show abrupt worsening in specific settings and thus further complicate the diagnostic workup. Awareness of the clinical and magnetic resonance imaging characteristics of different myelopathies and the specific settings where they occur is fundamental for a correct diagnosis. Neuroimaging helps distinguish compressive etiologies that may require urgent surgery from intrinsic etiologies that generally require medical treatment. Differentiation between various myelopathies is essential to establish timely and appropriate treatment and avoid harm from unnecessary procedures. This article reviews the contemporary spectrum of acute myelopathy etiologies and provides guidance for diagnosis and management.

Acute Neurologic Manifestations of Respiratory Viruses

PURPOSE OF REVIEW

Understanding the pathophysiology of COVID-19 and the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus that causes the disease has demonstrated the complexity of acute respiratory viruses that can cause neurologic manifestations. This article describes the most common respiratory viruses that have neurologic manifestations, with a focus on SARS-CoV-2 and COVID-19.

RECENT FINDINGS

In vitro and in vivo studies have better elucidated the neurotropism of various respiratory viruses. Understanding host cell receptors that mediate viral binding and entry not only demonstrates how viruses enter host cells but also provides possible mechanisms for therapeutic interventions. Elucidation of SARS-CoV-2 binding and fusion with host cells expressing the angiotensin-converting enzyme 2 (ACE2) receptor may also provide greater insights into its systemic and neurologic sequelae. Respiratory virus neurotropism and collateral injury due to concurrent inflammatory cascades result in various neurologic pathologies, including Guillain-Barré syndrome, encephalopathy, encephalitis, ischemic stroke, intracerebral hemorrhage, and seizures.

SUMMARY

Numerous respiratory viruses can infect the cells of the peripheral and central nervous systems, elicit inflammatory cascades, and directly and indirectly cause various neurologic manifestations. Patients with neurologic manifestations from respiratory viruses are often critically ill and require mechanical ventilation. Neurologists and neurointensivists should be familiar with the common neurologic manifestations of respiratory viruses and the unique and still-evolving sequelae associated with COVID-19.

Clinical Features, Laboratory, and Radiological Findings of Patients With Acute Inflammatory Myelopathy After COVID-19 Infection: A Narrative Review

ABSTRACT

The objective of this review was to analyze the existing data on acute inflammatory myelopathies associated with coronavirus disease 2019 infection, which were reported globally in 2020. PubMed, CENTRAL, MEDLINE, and online publication databases were searched. Thirty-three acute inflammatory myelopathy cases (among them, seven cases had associated brain lesions) associated with coronavirus disease 2019 infection were reported. Demyelinating change was seen in cervical and thoracic regions (27.3% each, separately). Simultaneous involvement of both regions, cervical and thoracic, was seen in 45.4% of the patients. Most acute inflammatory myelopathy disorders reported sensory motor and bowel bladder dysfunctions. On cerebrospinal fluid analysis, pleocytosis and increased protein were reported in 56.7% and 76.7% of the patients, respectively. Cerebrospinal fluid severe acute respiratory syndrome coronavirus 2 reverse transcriptase-polymerase chain reaction was positive in five patients. On T2-weighted imaging, longitudinally extensive transverse myelitis and short-segment demyelinating lesions were reported in 76% and 21%, respectively. Among the patients with longitudinally extensive transverse myelitis, 61% reported "moderate to significant" improvement and 26% demonstrated "no improvement" in the motor function of lower limbs. Demyelinating changes in the entire spinal cord were observed in three patients. Most of the patients with acute inflammatory myelopathy (including brain lesions) were treated with methylprednisolone (81.8%) and plasma-exchange therapy (42.4%). An early treatment, especially with intravenous methylprednisolone with or without immunoglobulin and plasma-exchange therapy, helped improve motor recovery in the patients with acute inflammatory myelopathy associated with coronavirus disease 2019.

Neurological complications of COVID-19: from pathophysiology to rehabilitation. An overview

OBJECTIVE

To evaluate how the SARS-COV2 is able to affect the nervous system, the main neurological manifestation, and the treatment used, including neurorehabilitation.

METHODS

Studies performed during the current year that fulfilled inclusion criteria were selected from PubMed, Scopus, Cochrane, and Web of Sciences databases. The search combined the terms "Covid 19," "rehabilitation/treatment," and "neurological complications."

RESULTS

The exact route by which SARS-CoV-2 can penetrate the CNS is still unknown, although a possible retrograde transynaptic pathway from peripheral nerve endings, and/or through the olfactory bulb, have been suggested. An early management of COVID-19 by a multiprofessional team is fundamental to avoid long term sequaele. Rehabilitation is recommended to improve respiratory and cardiac function, as well as to avoid long term neurological complications.

CONCLUSIONS

As no specific conclusions in term of prognosis and treatment could be done, research and consensus paper are needed to provide NeuroCovid patients with the best treatment options, including neurorehabilitation.

COVID-19 associated brain/spinal cord lesions and leptomeningeal enhancement: A meta-analysis of the relationship to CSF SARS-CoV-2

BACKGROUND AND PURPOSE

We reviewed the literature to evaluate cerebrospinal fluid (CSF) results from patients with coronavirus disease 2019 (COVID-19) who had neurological symptoms and had an MRI that showed (1) central nervous system (CNS) hyperintense lesions not attributed to ischemia and/or (2) leptomeningeal enhancement. We sought to determine if these findings were associated with a positive CSF severe acute respiratory syndrome associated coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR).

METHODS

We performed a systematic review of Medline and Embase from December 1, 2019 to November 18, 2020. CSF results were evaluated based on the presence/absence of (1) ≥ 1 CNS hyperintense lesion and (2) leptomeningeal enhancement.

RESULTS

In 117 publications, we identified 193 patients with COVID-19 who had an MRI of the CNS and CSF testing. There were 125 (65%) patients with CNS hyperintense lesions. Patients with CNS hyperintense lesions were significantly more likely to have a positive CSF SARS-CoV-2 PCR (10% [9/87] vs. 0% [0/43], p = 0.029). Of 75 patients who had a contrast MRI, there were 20 (27%) patients who had leptomeningeal enhancement. Patients with leptomeningeal enhancement were significantly more likely to have a positive CSF SARS-CoV-2 PCR (25% [4/16] vs. 5% [2/42], p = 0.024).

CONCLUSION

The presence of CNS hyperintense lesions or leptomeningeal enhancement on neuroimaging from patients with COVID-19 is associated with increased likelihood of a positive CSF SARS-CoV-2 PCR. However, a positive CSF SARS-CoV-2 PCR is uncommon in patients with these neuroimaging findings, suggesting they are often related to other etiologies, such as inflammation, hypoxia, or ischemia.

COVID-19-Associated Myelitis Involving the Dorsal and Lateral White Matter Tracts: A Case Series and Review of the Literature

Coronavirus disease 2019 (COVID-19) myelitis is a rare condition, most commonly presenting with nonenhancing central expansile cord T2 signal changes. A single case report has also described longitudinal involvement of the dorsal columns. We present 5 cases of COVID-19-associated myelitis with tract-specific involvement of the dorsal and lateral columns and discuss potential pathophysiologic pathways for this unique pattern.

Association of CNS demyelination and COVID-19 infection: an updated systematic review

Background

Since the declaration of COVID-19 pandemic, several case reports of demyelination of both peripheral and central nervous systems have been published. The association between CNS demyelination and viral infection has long been documented, and this link was recently reported following SARS-CoV-2 infection as well.

Objectives

In this systematic review, we aim to investigate the existing literature on CNS demyelination associated with SARS-CoV-2, and the proposed pathophysiological mechanisms.

Methods

We conducted a systematic review of articles in PubMed, SCOPUS, EMBASE, Cochrane, Google Scholar and Ovid databases, from 1 January 2020 until June 15, 2021. The following keywords were used: “COVID-19”, “SARS-CoV-2”, “demyelination”, “demyelinating disease”, “multiple sclerosis”, “neuromyelitis optica”, and “transverse myelitis”.

Results

A total of 60 articles were included in the final analysis of this systematic review and included 102 patients: 52 (51%) men and 50 (49%) women, with a median age of 46.5 years. The demyelination mimicked a variety of conditions with a picture of encephalitis/encephalomyelitis being the most common. At the same time other patterns were less frequently reported such as MS, NMOSD and even MOGAD. Longitudinally extensive transverse myelitis (LETM) was the most frequently reported pattern of spinal cord involvement.

Conclusion

A growing body of literature has shown an association between SARS‐CoV‐2 infection and the development of different types of CNS demyelination. Although causality cannot readily be inferred, this review may suggest a probable causal relationship, through a para-infectious or post-infectious immune-mediated etiology in COVID-19 patients. This relationship needs to be clarified in future research.

Age-Associated Neurological Complications of COVID-19: A Systematic Review and Meta-Analysis

The outbreak of the novel and highly infectious severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has resulted in hundreds of millions of infections and millions of deaths globally. Infected individuals that progress to coronavirus disease-19 (COVID-19) experience upper and lower respiratory complications that range in severity and may lead to wide-spread inflammation and generalized hypoxia or hypoxemia that impacts multiple organ systems, including the central and peripheral nervous systems. Since the SARS-CoV-2 outbreak, multiple reports continue to emerge that detail neurological symptoms, ranging from relatively mild (e.g., impaired taste and/or smell) to severe (e.g., stroke), suggesting SARS-CoV-2 may be neurotropic and/or contribute to nervous system injury through direct and/or indirect mechanisms. To gain insight into the types of neurological complications associated with SARS-CoV-2 infection and their possible relationship with age, sex, COVID-19 severity, and comorbidities, we performed a systematic review of case reports and series published in 2020 - April 4, 2021 of infected patients with neurological manifestations. Meta-analyses were conducted using individual patient data from reports where these data could be extracted. Here, we report neurological injury occurs across the lifespan in the context of infection, with and without known comorbidities, and with all disease severities, including asymptomatic patients. Older individuals, however, are more susceptible to developing life-threatening COVID-19 and cerebrovascular disease (CVD), such as stroke. A mild but inverse correlation with age was seen with CNS inflammatory diseases, such as encephalitis, as well as taste and/or smell disorders. When reported, increased age was also associated with comorbid cardiovascular risk factors, including hypertension, diabetes mellitus, and lipid disorders, but not with obesity. Obesity did correlate with development of critical COVID-19. Discussion into potential pathophysiological mechanisms by which neurological symptoms arise and long-term consequences of infection to the nervous system is also provided.

Comprehensive Review on Neuro-COVID-19 Pathophysiology and Clinical Consequences

Aside from the respiratory distress as the predominant clinical presentation of SARS-CoV-2 infection, various neurological complications have been reported with the infection during the ongoing pandemic, some of which cause serious morbidity and mortality. Herein, we gather the latest anatomical evidence of the virus's presence within the central nervous system. We then delve into the possible SARS-CoV-2 entry routes into the neurological tissues, with the hematogenous and the neuronal routes as the two utmost passage routes into the nervous system. We then give a comprehensive review of the neurological manifestations of the SARS-CoV-2 invasion in both the central and peripheral nervous system and its underlying pathophysiology via investigating large studies in the field and case reports in cases of study scarcity.

Guillain Barrè syndrome and myelitis associated with SARS-CoV-2 infection

Despite a likely underestimation due to the many obstacles of the highly infectious, intensive care setting, increasing clinical reports about COVID-19 patients developing acute paralysis for polyradiculoneuritis or myelitis determine additional impact on the disease course and outcome. Different pathogenic mechanisms have been postulated basing on clinical, laboratory and neuroimaging features, and response to treatments. Here we provide an overview with insights built on the available reports. Besides direct viral pathogenicity, a crucial role seems to be represented by immune-mediated mechanisms, supporting and further characterizing the already hypothesized neurotropic potential of SARS-CoV-2 and implying specific treatments. Proper clinical and instrumental depiction of symptomatic cases, as well as screening for their early recognition is advocated.

MRI negative myelopathy post mild SARS-CoV-2 infection: vasculopathy or inflammatory myelitis?

Since the onset of the COVID-19 pandemic, there have been rare reports of spinal cord pathology diagnosed as inflammatory myelopathy and suspected spinal cord ischemia after SARS-CoV-2 infection. Herein, we report five cases of clinical myelopathy and myeloradiculopathy in the setting of post-COVID-19 disease, which were all radiographically negative. Unlike prior reports which typically characterized hospitalized patients with severe COVID-19 disease and critical illness, these patients typically had asymptomatic or mild-moderate COVID-19 disease and lacked radiologic evidence of structural spinal cord abnormality. This case series highlights that COVID-19 associated myelopathy is not rare, requires a high degree of clinical suspicion as imaging markers may be negative, and raises several possible pathophysiologic mechanisms.

SARS-CoV-2 RNA detection in cerebrospinal fluid: Presentation of two cases and review of literature

Neurological manifestations of SARS-CoV-2 infection are multiple and heterogeneous. However, confirmation of nervous system impairment by viral RNA detection in cerebrospinal fluid (CSF) is uncommon. We report two cases of central nervous system (CNS) involvement with positive real-time reverse-transcriptase polymerase chain reaction (RT-PCR) test in CSF.

COVID-19, Neuropathology, and Aging: SARS-CoV-2 Neurological Infection, Mechanism, and Associated Complications

The spectrum of health complications instigated by coronavirus disease 2019 (COVID-19, caused by the novel severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2) pandemic has been diverse and complex. Besides the evident pulmonary and cardiovascular threats, accumulating clinical data points to several neurological complications, which are more common in elderly COVID-19 patients. Recent pieces of evidence have marked events of neuro infection and neuroinvasion, producing several neurological complications in COVID-19 patients; however, a systematic understanding of neuro-pathophysiology and manifested neurological complications, more specifically in elderly COVID-19 patients is largely elusive. Since the elderly population gradually develops neurological disorders with aging, COVID-19 inevitably poses a higher risk of neurological manifestations to the aged patients. In this report, we reviewed SARS-CoV-2 infection and its role in neurological manifestations with an emphasis on the elderly population. We reviewed neuropathological events including neuroinfection, neuroinvasion, and their underlying mechanisms affecting neuromuscular, central- and peripheral- nervous systems. We further assessed the imminent neurological challenges in the COVID-19 exposed population, post-SARS-CoV-2-infection. Given the present state of clinical preparedness, the emerging role of AI and machine learning was also discussed concerning COVID-19 diagnostics and its management. Taken together, the present review summarizes neurological outcomes of SARS-CoV-2 infection and associated complications, specifically in elderly patients, and underlines the need for their clinical management in advance.

Systematic review of cases of acute myelitis in individuals with COVID-19

Background and purpose

An incremental number of cases of acute transverse myelitis (ATM) in individuals with ongoing or recent coronavirus disease 2019 (COVID‐19) have been reported.

Methods

A systematic review was performed of cases of ATM described in the context of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection by screening both articles published and in preprint.

Results

Twenty cases were identified. There was a slight male predominance (60.0%) and the median age was 56 years. Neurological symptoms first manifested after a mean of 10.3 days from the first onset of classical, mostly respiratory symptoms of COVID‐19. Overall, COVID‐19 severity was relatively mild. Polymerase chain reaction of cerebrospinal fluid for SARS‐CoV‐2 was negative in all 14 cases examined. Cerebrospinal fluid findings reflected an inflammatory process in most instances (77.8%). Aquaporin‐4 and myelin oligodendrocyte protein antibodies in serum (tested in 10 and nine cases, respectively) were negative. On magnetic resonance imaging, the spinal cord lesions spanned a mean of 9.8 vertebral segments, necrotic‐hemorrhagic transformation was present in three cases and two individuals had additional acute motor axonal neuropathy. More than half of the patients received a second immunotherapy regimen. Over a limited follow‐up period of several weeks, 90% of individuals recovered either partially or near fully.

Conclusion

Although causality cannot readily be inferred, it is possible that cases of ATM occur para‐ or post‐infectiously in COVID‐19. All identified reports are anecdotal and case descriptions are heterogeneous. Whether the condition and the observed radiological characteristics are specific to SARS‐CoV‐2 infection needs to be clarified.

COVID-19 and emerging spinal cord complications: A systematic review

BACKGROUND

Spinal cord complications associated with coronavirus infectious disease of 2019 (COVID-19) are being widely reported. The purpose of this systematic review was to summarize so far available pieces of evidence documenting de novo novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) mediated spinal cord demyelinating diseases. Indeed, the spinal demyelinating disorders that have been reported in those patients who have suffered from COVID-19 rather than on the people already living with diagnosed or undiagnosed primary demyelinating disorders.

METHODS

We used the existing PRISMA consensus statement. Data were collected from PubMed, NIH Litcovid, EMBASE and Cochrane library databases, as well as Pre-print servers (medRxiv, bioRxiv, and pre-preints.org), until September 10, 2020, using pre-specified searching strategies.

RESULTS

The 21 selected articles were all case reports and included 11 (52%) men and 10 (48%) women. The mean age was of 46.7 ± 18.0. The neurological manifestations included weakness, sensory deficit, autonomic dysfunction and ataxia. In most cases, elevated cerebrospinal fluid protein as well as lymphocytic pleocytosis were found. SARS-CoV-2 was detected in five (24%) patients, meanwhile in 13 (62%) patients, the testing was negative. Testing was not performed in two cases and, in one, data were unavailable. Nearly half of the cases (N = 9) were associated with isolated long extensive transverse myelitis (LETM), whereas a combination of both LETM and patchy involvement was found in two. Only five patients had isolated short segment involvement and two patchy involvement. Furthermore, concomitant demyelination of both brain and spine was reported in six patients. Concerning the prognosis, most of the patients improved and the mortality rate was low (N = 2, <10%).

CONCLUSION

Spinal cord demyelination should be added to the plethora of immune mediated neurologic complications associated with COVID-19.

Infectious and immune-mediated central nervous system disease in 48 COVID-19 patients

Objectives

To summarise and discuss current knowledge about SARS-CoV-2-associated infectious/immune-mediated central nervous system (CNS)-disease.

Method

Literature review.

Results

Altogether 28 articles were found, which reported 48 patients with SARS-CoV-2-associated infectious/immune-mediated CNS-disease. Age ranged from 22 to 79y. There was male preponderance. There were 14 patients with infectious CNS-disease (meningitis (n = 1), encephalitis (n = 5), meningo-encephalitis (n = 5), myelitis (n = 3)), and 34 patients with parainfectious CNS-disease (encephalopathy (n = 18), autoimmune encephalitis (n = 11), acute, disseminated, encephalo-myelitis (n = 3), acute, haemorrhagic, necrotizing encephalopathy (n = 2)). The cerebrospinal fluid (CSF) was tested for SARS-CoV-2 in 40 patients and was positive for the virus in 4 patients with infectious CNS-disease but was negative for the virus in all patients with parainfectious CNS-disease. Immune-modulating treatment may be more effective than virostatics/antibiotics for SARS-CoV-2-associated infectious/parainfectious, non-vascular, non-hypoxic CNS-disease. In patients with autoimmune encephalitis plasmapheresis may be beneficial. Twenty-two patients recovered, 2 did not, and 6 patients died.

Conclusions

SARS-CoV-2 can cause infectious/immune-mediated CNS-disease. The CSF is positive for virus-RNA in only few patients with infectious CNS-disease but negative for virus-RNA in immune-mediated CNS-disease, suggesting an immune-mediated pathophysiological mechanism. The outcome of SARS-CoV-2-associated infectious/immune-mediated CNS-disease is favourable in the majority of cases but can be fatal in single cases.

A Case of Elsberg Syndrome in the Setting of Asymptomatic SARS-CoV-2 Infection

ABSTRACT

Elsberg syndrome is a rare cause of lumbosacral radiculitis with concomitant thoracic and lumbosacral myelitis that can be seen after an acute or reactivated viral infection. After the initial coronavirus surge in New York City, a 68-year-old man developed progressive lower extremity weakness and a defined sensory level at the lower abdomen. He had highly elevated SARS-CoV-2 IgG antibodies despite an absence of preceding COVID-19 symptoms. Serial electrodiagnostic testing revealed absent lower extremity late responses, with otherwise normal distal sensorimotor conductions. Electromyography revealed active neurogenic changes and reduced motor unit recruitment in the L3-L4 myotomes. Treatment with methylprednisolone and intravenous immunoglobulin was followed by minimal clinical improvement but re-emergence of the lower extremity late responses on electrodiagnostic testing. We report here, to the best of our knowledge, the first case of suspected COVID-19-associated Elsberg syndrome, which expands the spectrum of neuromuscular manifestations associated with SARS-CoV-2 infection and sheds light on ways to approach diagnostic and treatment options for these patients.

COVID-19 and neuroinflammation: a literature review of relevant neuroimaging and CSF markers in central nervous system inflammatory disorders from SARS-COV2

BACKGROUND

The literature on neurological manifestations in COVID-19 patients has been rapidly increasing with the pandemic. However, data on CNS inflammatory disorders in COVID-19 are still evolving. We performed a literature review of CNS inflammatory disorders associated with coronavirus disease-2019 (COVID-19).

METHODS

We screened all articles resulting from a search of PubMed, Google Scholar and Scopus, using the keywords; "SARS-CoV-2 and neurological complication", "SARS-CoV-2 and CNS Complication" looking for reports of transverse myelitis, longitudinally extensive transverse myelitis, neuromyelitis optica, myelitis, Myelin Oligodendrocyte Glycoprotein Antibody Disorder (MOGAD), Acute Disseminated Encephalomyelitis (ADEM), Acute Hemorrhagic Necrotizing Encephalitis/Acute Hemorrhagic Leukoencephalitis (AHNE/AHLE), Cytotoxic lesion of the Corpus Callosum/Mild Encephalopathy Reversible Splenium Lesion(CLOCC/MERS) and Optic neuritis published between December 01, 2019 and March 15, 2021.

RESULTS

Our literature search revealed 43 patients meeting the diagnosis of myelitis, including Transverse Myelitis, ADEM, AHNE/AHLE or CLOCC/MERS and Optic neuritis. Acute myelitis was most commonly associated with non-severe COVID-19 and all reported cases of AHNE/AHLE had severe COVID-19 infection. Based on IDSA/ATS criteria of either requiring vasopressor for septic shock or mechanical ventilation, 49% (n = 18) patients were considered to have a severe COVID infection. There were 7 (n = 19%) fatalities.

CONCLUSION

To our knowledge, this is among the first reviews that includes the clinical features, neuroimaging, CSF findings and outcomes in COVID-19-associated CNS inflammatory disorders. Our observational review study reveals that although rare, myelitis, ADEM, AHNE and CLOCC can be associated with COVID-19 infection. Further studies using MRI imaging and CSF analysis in early diagnosis and intervention of these disorders are warranted.

Acute Transverse Myelitis (ATM):Clinical Review of 43 Patients With COVID-19-Associated ATM and 3 Post-Vaccination ATM Serious Adverse Events With the ChAdOx1 nCoV-19 Vaccine (AZD1222)

Introduction

Although acute transverse myelitis (ATM) is a rare neurological condition (1.34-4.6 cases per million/year) COVID-19-associated ATM cases have occurred during the pandemic.

Case-finding methods

We report a patient from Panama with SARS-CoV-2 infection complicated by ATM and present a comprehensive clinical review of 43 patients with COVID-19-associated ATM from 21 countries published from March 2020 to January 2021. In addition, 3 cases of ATM were reported as serious adverse events during the clinical trials of the COVID-19 vaccine ChAdOx1 nCoV-19 (AZD1222).

Results

All patients had typical features of ATM with acute onset of paralysis, sensory level and sphincter deficits due to spinal cord lesions demonstrated by imaging. There were 23 males (53%) and 20 females (47%) ranging from ages 21- to 73- years-old (mean age, 49 years), with two peaks at 29 and 58 years, excluding 3 pediatric cases. The main clinical manifestations were quadriplegia (58%) and paraplegia (42%). MRI reports were available in 40 patients; localized ATM lesions affected ≤3 cord segments (12 cases, 30%) at cervical (5 cases) and thoracic cord levels (7 cases); 28 cases (70%) had longitudinally-extensive ATM (LEATM) involving ≥4 spinal cord segments (cervicothoracic in 18 cases and thoracolumbar-sacral in 10 patients). Acute disseminated encephalomyelitis (ADEM) occurred in 8 patients, mainly women (67%) ranging from 27- to 64-years-old. Three ATM patients also had blindness from myeloneuritis optica (MNO) and two more also had acute motor axonal neuropathy (AMAN).

Conclusions

We found ATM to be an unexpectedly frequent neurological complication of COVID-19. Most cases (68%) had a latency of 10 days to 6 weeks that may indicate post-infectious neurological complications mediated by the host’s response to the virus. In 32% a brief latency (15 hours to 5 days) suggested a direct neurotropic effect of SARS-CoV-2. The occurrence of 3 reported ATM adverse effects among 11,636 participants in the AZD1222 vaccine trials is extremely high considering a worldwide incidence of 0.5/million COVID-19-associated ATM cases found in this report. The pathogenesis of ATM remains unknown, but it is conceivable that SARS-CoV-2 antigens –perhaps also present in the AZD1222 COVID-19 vaccine or its chimpanzee adenovirus adjuvant– may induce immune mechanisms leading to the myelitis.

Myelopathy associated with SARS-COV-2 infection. A systematic review

Background׃COVID-19 (CoranaVirus disease 2019) is an ongoing infectious disease caused by the RNA SARS-CoV-2 virus (Severe Acute Respiratory Syndrome CoronaVirus-2). More than one-third of COVID-19 patients report neurological symptoms and cases of neurological diseases are increasingly accumulating. The aim of this systematic review was to characterize all - to date - reported cases with COVID-19 related myelopathy. Methods׃Eighteen papers were included in this review. Patients of all ages could be affected, although there is a predilection for middle-aged people. Results׃There were no significant co-morbidities or immunodeficiencies in the affected patients. COVID-19 related myelopathy started roughly within the first month after COVID-19 onset, either concomitantly with COVID-19 symptoms or within 10 days after their remission. The vast majority of cases fulfilled our criteria for postinfectious transverse myelitis. However, some cases were considered to have had parainfectious or infectious myelitis or, in one case, vascular myelopathy. Motor, sensory and bowel and/or bladder symptoms predominated the clinical presentation of myelopathies, explained mainly by centrally localized and longitudinally extensive lesions within the cervical and/or thoracic segments of the spinal cord. Occasionally lesions were complicated by necrosis and hemorrhages. Treatment with corticosteroids, intravenous immunoglobulin or plasma exchange was offered mostly a mild to marked improvement within a period of some weeks. Conclusions׃ Considering the imminent arrival of new vaccines against COVID-19 pandemic, and their potential risk for postvaccination transverse myelitis, this characterization of COVID-19 related myelopathy is of utmost importance.

Current Immunological and Clinical Perspective on Vaccinations in Multiple Sclerosis Patients: Are They Safe after All?

Vaccines work by stimulating the immune system, and their immunogenicity is key in achieving protection against specific pathogens. Questions have been raised whether in Multiple Sclerosis (MS) patients they could induce disease exacerbation and whether vaccines could possibly act as a trigger in the onset of MS in susceptible populations. So far, no correlation has been found between the vaccinations against influenza, hepatitis B, tetanus, human papillomavirus, measles, mumps, rubella, varicella zoster, tuberculosis, yellow fever, or typhoid fever and the risk of MS. Further research is needed for the potential protective implications of the tetanus and Bacillus Calmette-Guerin vaccines in MS patients. Nowadays with the emerging coronavirus disease 2019 (COVID-19) and recent vaccinations approval and arrival, the risk-benefit in MS patients with regards to safety and efficacy of COVID-19 vaccination in those treated with immunosuppressive therapies is of paramount importance. In this manuscript, we demonstrate how different vaccine types could be related to the immunopathogenesis of MS and discuss the risks and benefits of different vaccinations in MS patients.

Para-infectious anti-GD2/GD3 IgM myelitis during the Covid-19 pandemic: Case report and literature review

BACKGROUND

Even though SARS-CoV-2 is a predominantly respiratory virus, several reports have described various neurological disorders, from the beginning of the pandemic. The first para-infectious myelitis case was described in Wuhan in February 2020. Nevertheless, data from registries and reviews are scarce.

METHODS

A 40-year-old female with T5-T6 SARS-CoV-2 para-infectious myelitis is reported. A literature review of the published literature on the SARS-CoV-2 and para-infectious myelitis was done. Epidemiological, clinical, laboratory, image, treatment, and outcome data are described.

RESULTS

Particular findings of our case are that Covid-19 was asymptomatic and anti-GD2/GD3 IgM was found. 18 para-infectious myelitis occurred over a wide age range (Beh et al., 2013-67), mean age 50.7±18.6 years, with 10/18 (55.6%) women. Covid-19 involvement was variable from asymptomatic cases to severe Covid-19 resulting in death. The mean time to establish myelitis from the onset of Covid-19 symptoms was 10.3 ±7.8 days (0-24). The most common clinical form was transverse myelitis (14/18 patients, 77.7%) and the most frequent radiological form was longitudinally extensive myelitis (11/17 patients, 64.7%). In CSF mild lymphocytosis (14/16, 87.5%) with low cellularity (40.9±49.7/μL) and elevated proteins (11/16, 77.8%, mean 145.0 mg±159.0/dL) were frequent. Oligoclonal bands were usually negative (7/9, 77.7%) and mirror pattern was found in 2/7 patients (33.3%). SARS-CoV-2 PCR in CSF was negative in 10/10 cases.

CONCLUSION

SARS-CoV-2 can cause myelitis by immune-mediated mechanisms. Clinical-radiological characteristics of Covid-19 para-infectious myelitis were variable and non-specific.

Spinal cord involvement in COVID-19: A review

CONTEXT

Recent literature points towards myelitis, like encephalitis, as a common central nervous system complication of COVID-19. This review elaborates on disorders of the spinal cord caused by the SARS-CoV-2 virus.

OBJECTIVES

To review the published data about SARS-CoV-2-associated spinal cord disorders and assess their clinical, neuroimaging, treatment, and prognostic aspects.

METHODS

The PubMed and Google Scholar databases were searched for published cases using the search items "COVID-19 OR SARS-CoV-2 AND myelitis", "COVID-19 OR SARS-CoV-2 AND myelopathy", and "COVID-19 OR SARS-CoV-2 AND spinal cord".

RESULTS

Thirty-three isolated cases were included in the present review, of which 14 were aged 60 years and above (range: 3-70 years). Eighteen patients had lung abnormalities on chest imaging. Eight patients had developed either an areflexic paraparesis or quadriparesis. In 17 patients, neuroimaging demonstrated longitudinally extensive transverse myelitis, while 3 cases showed neuroimaging changes in the spinal cord as a part of acute disseminated encephalomyelitis syndrome. Cerebrospinal fluid (CSF) examinations revealed inflammatory changes in 18 patients. However, the SARS-CoV-2 virus in the CSF was discovered in 2 patients. In 2 patients, anti-SARS-CoV-2 antibodies were demonstrated in the CSF. Following treatment, 13 patients were able to walk.

CONCLUSIONS

A variety of COVID-19-related spinal cord manifestations, such as acute transverse myelitis, acute necrotizing myelitis, SARS-CoV-2 myelitis, acute disseminated encephalomyelitis, neuromyelitis optica spectrum disorder, hypoxic myelopathy, MOG antibody-associated myelitis, spinal cord infarction, and spinal epidural abscess, have been reported. The possible mechanisms of this involvement being direct invasion, cytokine storm, coagulopathy, and an autoimmune response. However, response to treatment has been generally unsatisfactory, with many patients having residual weakness necessitating long-term rehabilitation.

Cervical spinal cord infarction associated with coronavirus infectious disease (COVID)-19

Coronavirus disease (COVID-19) has a number of emerging neurological manifestations in addition to pneumonia and respiratory distress. In what follows, we describe a case of a previously healthy young man with severe COVID-19 who subsequently developed an acute flaccid paralysis. Work up revealed a lesion in his cervical spinal cord concerning for spinal infarction or transverse myelitis. He received empiric pulsed steroids without improvement. Taken together, we felt his presentation was most consistent with spinal cord infarction in the setting of critical illness with COVID-19. We believe this is a rare case of spinal cord stroke associated with COVID-19.

[Effects of COVID-19 on the central nervous system]

This review examines the current data on central nervous system damage in cases of the new coronavirus infection caused by the COVID-19 virus. The pathogenetic mechanisms leading to damage to the brain and spinal cord are considered. The analysis of available research articles and meta-analyzes published up to fall 2020 is carried out. The authors provide the results of their own clinical observations of various forms of damage to the central nervous system in cases of COVID-19 virus disease. Particular attention is paid to certain common forms of damage to the central nervous system, such as encephalitis, cerebrovascular pathology, and headaches. A form of acute hemorrhagic necrotizing encephalopathy is distinguished, which is a rather rare but fatal pathology, comorbid with the COVID-19 virus. The data of our own clinical case of acute necrotizing encephalopathy are presented. The importance of further studying the effect of coronavirus on the central nervous system and possible mechanisms of therapy and rehabilitation for this category of patients is emphasized.