Table 1.
Clinical, laboratory and neuroimaging features in COVID-19 patients with acute myelopathies.
| Case 1 | Case 2 | Case 3 | |
|---|---|---|---|
| Subject demographics | Female, 25 y-o | Female, 50 y-o | Male, 69 y-o |
| Medical history | – | Essential tremor | Hypertension, dyslipidemia |
| COVID-19 symptoms | Mild (fever, anosmia, dysgeusia) | Mild (fever) | Moderate (fever, asthenia, interstitial pneumonia) |
| Exposure to proven COVID-19 cases | Untraceable | Workmates | Wife |
| COVID-19 treatment | Acetaminophen | HCQ 200 mg bid for 7 days, azithromycin 500 mg for 5 days, amoxicillin/clavulanate 875/125 mg bid for 7 days and celecoxib | Amoxicillin/clavulanate 875/125 mg bid for 2 days |
| CNS Neurological features | Sub-acute paraplegia, sensory impairment with upper thoracic level, bladder dysfunction | Sub-acute sensorimotor impairment to the lower limbs with gait ataxia | Acute flaccid paraplegia, sensory impairment with mid thoracic level, bladder and bowel dysfunction |
| Latency/Overlap between infectious and neurological onset | 15 days/No | 15 days/No | 3 days/Yes |
| Lab tests (at admission) | Normal | Normal | WBC 6,6/mmc Ly 1,2/mmc CRP 151 mg/l Ferritin 1422 ng/ml LDH 592 U/L |
| Chest imaging during hospitalization | Negative | Negative | Interstitial pneumonia |
| SARS-CoV-2 RT-PCR (swab) – performed after symptom onset: | Positive | Negative (not performed during the infectious course) | Positive |
|
20 days | 30 days | 3 days |
|
5 days | 15 days | <1 day |
| Brain neuroimaging | MRI: Normal findings | MRI: Single periventricular lesion (Fig. 1, II) | MRI: Single lesion in the left superior cerebellar peduncle (Fig. 1, III) |
| Spine neuroimaging | MRI: Multiple lesions (cervical and thoracic spinal cord) (Fig. 1, I) | MRI: Two lesions (one extending from the bulbo-medullary junction down to C6, one located at the conus) (Fig. 1, II) | MRI: Multiple lesions (cervical and upper thoracic spinal cord, LETM extending from mid-thoracic down to the epiconus) (Fig. 1, III) |
| CSF findings | Slight lymphomonocytic pleocytosis (8 cells/mmc), no OCBs | Moderate lymphomonocytic pleocytosis (65 cells/mmc), hyperproteinorrachia (161.2 mg/dl), slight hypoglycorrachia (41 mg/dl), no OCBs | Marked neutrophilic pleocytosis (672 cells/mmc), hyperproteinorrachia (90 mg/dl), normal glucose, “mirror pattern” OCBs. Control CSF (after 5 days): reduced pleocytosis (26 cells/mmc) and hyperproteinorrachia (58 mg/dl), normal glucose, no OCBs |
| Neurophysiology | Motor evoked potentials: temporal dispersion, normal central conduction times. EMG/ENG: normal. |
Somatosensory evoked potentials: delayed latency for cortical response with lower limbs stimulation. EMG/ENG: normal. |
Motor evoked potentials: no response for lower limbs. EMG/ENG: “polio-like syndrome” in lower limbs (reduced amplitude of compound motor action potentials, reduced recruitment pattern, presence of denervation potentials on needle EMG, absent F wave responses) |
| SARS-CoV-2 RT-PCR on CSF | Negative | N.P. | Negative |
| Diagnosis | Post-infectious demyelinating myelitis | Post-infectious encephalomyelitis | Para-infectious demyelinating and polio-like encephalomyelitis |
| Treatment | M-P 1 g OD for 7 days | Ceftriaxone 2 g x 2 for 5 days, Ampicillin 2 g x 6 for 5 days, Acyclovir 750 mg x 3 for 3 days M-P 1 g OD for 5 days, 500 mg OD for 3 days, 250 mg OD for 3 days |
Ceftriaxone 2 g x 2 for 10 days, acyclovir 750 mg x 3 for 5 days, lopinavir/ritonavir 400/100 mg and HCQ 200 mg x 2 for 14 days M-P 1 g OD for 7 days; IVIg 0.4 g/kg OD for 5 days |
| Clinical follow up | After 2 weeks; discharged to rehab with paraplegia and sensory gait ataxia, able to walk with a walker After 3 months: Discharged home, able to walk with a walker, mild sensory gait ataxia |
After 2 weeks: discharged to rehab with moderate gait ataxia After 3 month: Slight gait ataxia, able to walk without devices |
After 3 weeks: discharged to rehab with severe paraplegia, unable to stand After 3 months: Still in rehab, moderate improvement of strength, able to walk with a walker and assistanc |
Abbreviations: y-o, year-old; F, female; M, male; CNS, central nervous system; Ly, lymphocytes; CSF, cerebrospinal fluid; OCBs, oligoclonal bands; LETM, longitudinal elongated transverse myelitis; N.P., not performed; OD, omne in die; bid, bis in die; M-P, methylprednisolone; HCQ, hydroxychloroquine; IVIg, intravenous immunoglobulins.