Methylprednisolone/prednisone/rivaroxaban

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

In a case series of patients with COVID-19 (diagnosed between 1 July 2020 and 10 August 2020), a 60-year-old woman and a 21-year-old woman were described, who exhibited a lack of efficacy during treatment with methylprednisolone, prednisone or rivaroxaban for transverse myelitis or cervicothoracic myelopathy [not all routes and dosages stated].

A 60-year-old woman was hospitalised in 2020 with a 3-day history of dry cough and high-grade fever, followed by numbness and weakness of both the lower limbs. She had a history of hypothyroidism, which was treated with levothyroxine sodium [Eltroxine]. No family or personal history of neurological disorders was reported. She did not receive any vaccination in previous months. On examination, she was diagnosed with transverse myelitis associated with COVID-19. Hence, she received treatment IV methylprednisolone 1g for 5 days, followed by slow oral prednisone tapering for two weeks. However, no improvement was observed. Hence, she received 5 sessions of plasmapheresis, but with no improvement. After the fourth session of plasmapheresis, she developed right iliofemoral deep venous thrombosis. Hence, she was treated with low molecular heparin for 5 days, which resulted in an improvement in the deep venous thrombosis. However, lower limb paralysis persisted. After a few days, she developed a severe attack of dyspnoea and cyanosis with pulmonary embolism. She was ventilated, but she died a few hours later.

A 21-year-old woman presented to the clinic in 2020 with a 10-day history of anosmia, high-grade fever and dry cough, followed by acute onset flaccid paralysis and numbness of both the lower limbs with difficulty in voiding. On examination, she was diagnosed with COVID-19. No recent vaccinations were reported. Based on the findings, the possibility of transverse myelitis was considered as a differential diagnosis of long segment myelopathy. However, the complete preservation of deep sensation supported the diagnosis of anterior spinal artery occlusion (cervicothoracic myelopathy). Hence, she was treated with IV methylprednisolone 1g for 5 days with no improvement. Her treatment with methylprednisolone was gradually stopped over the following 10 days. Subsequently, she received rivaroxaban 20 mg/day for 30 days, along with passive exercise and short wave therapy. However, no improvement was observed. Therefore, she was treated with IV immune globulin [IVIG] for 5 days. Her upper limb strength improved, while lower limbs remained flaccid.