Table 3.
Characteristics of cases presenting with COVID-19 related isolated myelitis
| Author | Age | Gender | Comorbidities | Time relation between infection and NP | Presenting COVID-19 symptoms | Presenting neurological symptoms | Neurological diagnosis | Other NS manifestations | Treatment | Response to treatment | Testing for SARS-COV-2 | Severity of COVID-19 infection | Antibody and OCBs testing | MRI data |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1. Valiuddin [64] | 61 | Female | None | A week | Rhinorrhea, chills and generalized weakness | Numbness and tingling in hands and feet, weakness in both lower limbs and upper limbs, constipation and urine retention |
Acute COVID myelitis (LETM) |
Acute Motor Axonal Neuropathy (AMAN) | IVMP for 5 days, 5 sessions PLEX |
No improvement Mild improvement |
Positive PCR in nasopharynx, negative in CSF | Mild | NA | Cervico-thoraco-lumbar spine: LETM without pathological contrast enhancement |
| 2. Moreno-Escobar [65] | 41 | Male | None | A week | Headache, nausea and low-grade fever, fatigue and myalgia |
Paresthesia of bilateral upper and lower extremities along with urinary and fecal retention Weakness of both lower limbs |
Post COVID-19 myelitis vs NMOSD (LETM) | Dysautonomia | IVMP for 5 days with oral taper | Partial | Positive PCR in nasopharynx | Mild | Negative OCBs, AQP4 and MOG antibodies | Cervical and thoracic spinal: LETM without any abnormal enhancement |
| 3. Munz et al. [66] | 60 | Male | HTN, fatty liver, ureterolithiasis | 3 days | Respiratory symptoms | Bladder dysfunction and progressive weakness of the lower limbs | Post-COVID myelitis | None | IV Acyclovir and ceftriaxone, IVMP 100 mg/day | Marked but partial | Positive PCR in nasopharynx, negative in CSF | Moderate | Negative OCBs |
Thoracic spinal: T2 signal hyperintensity of the thoracic spinal cord at Th9 level suggestive of acute transverse myelitis rather than multiple sclerosis FUP after 6 days: a patchy hyper- intensity of the thoracic cord at Th9-10 and at Th3-5 level, suggestive of transverse myelitis |
| 4. Sarma et al. [67] | 28 | Female | Hypothyroidism | At initial presentation | Productive cough, fever, myalgia, rhinorrhea | Low back pain, paresthesia in both lower limbs, urine retention, nausea and vomiting | Immune mediated COVID-myelitis (LETM) | None | Prednisolone and received two PLEX treatments | Partial | Positive PCR in nasopharynx | Mild | NA | Spine: widespread elongated signal changes throughout the spinal cord to the conus medullaris and involving the medulla (LETM) |
| 5. Sotoca et al. [68] | 69 | Female | None | 8 days | Fever and cough | Irradiated cervical pain, imbalance, and motor weakness and numbness in the left hand | Acute necrotizing myelitis (ANM) (LETM) | None | IVMP for 5 days, PLEX and another course of IVMP for 5 days with oral taper | Partial then deteriorated and new attack | Positive PCR in nasopharynx, negative in CSF | Mild | Negative OCBs, MOG and AQP4 antibodies |
Spinal: LETM extending from the medulla oblongata to C7, involving most of the cord with diffuse patchy enhancing lesions A new spinal MRI after deterioration: transversally and caudally progression until T6 level with similar enhancement and a new area of central necrosis at the T1 level with peripheral enhancement FUP MRI after PLEX: substantial decrease in myelitis extension and enhancement, but central necrosis at the C7-T1 level remained unchanged |
| 6. Domingues et al. [69] | 42 | Female | None |
3 weeks Symptoms overlapped |
Coryza, nasal obstruction | Recurrent paresthesia of the left upper limb, later progressing to left hemithorax, and hemiface (these symptoms occurred 3 years ago) | Spinal CIS vs viral myelitis | None | No treatment received | Full spontaneous recovery after 3 weeks | Positive PCR in CSF, negative in nasopharynx | Definite | NA | Cervical: small lateral demyelinating patch that explains the symptoms |
| 7. Alketbi et al. [70] | 32 | Male | None | 2 days | High-grade fever and flu-like symptoms | Sudden onset of bilateral lower limb weakness, difficulty in sitting up, and in passing urine | Post-COVID-19 myelitis (LETM) | None | IVMP for 5 days | Marked partial | Positive PCR in nasopharynx | Mild | NA | Spinal: LETM |
| 8. Durrani et al. [71] | 24 | Male | None | 12 days | Fever, chills, nausea and vomiting | Bilateral lower extremity weakness in addition to developing overflow urinary incontinence |
Post COVID- 19 myelitis vs COVID-19 myelitis (LETM) |
None | IVMP | Marked | Positive PCR in nasopharynx | Moderate | Negative OCBs | Spinal: LETM |
| 9. Abdelhady et al. [71] | 52 | Male | DM, G6PD deficiency | At initial presentation | Fever | Lower abdominal pain and inability to pass urine for the past 3 days, associated with fever and lower limb weakness | COVID-19 myelitis (LETM) | None | Steroids and acyclovir | Died | Positive PCR in nasopharynx, negative in CSF | Mild | NA | Thoracic spinal: LETM |
| 10. Chow et al. [72] | 60 | Male | HTN. Hypercholesterolemia, ex smoker | 18 days | Fever, cough, loss of taste and smell | Bilateral lower limb weakness, urinary retention and constipation | ATM (LETM) | None | IVMP for 3 days, physiotherapy | Complete neurological and radiological improvement | Positive PCR in nasopharynx | Mild | Negative serum anti-MOG, anti-MAG, and AQP4 antibodies |
Whole spine: LETM Normal MRI brain and orbit Follow-up MRI whole spine after 10 days showed almost complete resolution |
| 11. Kaur et al. [73] | 3 | Female | None | At initial presentation | Asymptomatic | Flaccid quadriparesis, neurogenic respiratory failure requiring intubation | ATM (LETM) | None | IVMP for 5 days (30 mg/kg/day) and IVIG (2 g/kg total dose), then seven sessions of PLEX, then Rituximab | No improvement | Positive PCR in nasopharynx | Mild | Negative serum AQP4 and MOG autoantibodies |
Spine: LETM of cervical spinal cord extending from the lower medulla to the mid-thoracic level with no enhancement Brain and orbits: were normal Follow-up MRI: reduced edema, early cervical myelomalacia |
| 12. Masuccio et al. [74] | 70 | Female | HTN, obesity | 15 days | Fever, anosmia and generalized myalgia | Severe quadriparesis, decreased tactile and pain sensation in the lower limbs accompanied with urinary retention | ATM | Acute motor axonal neuropathy (AMAN) | PLEX followed by one course of IVIG | No improvement | Negative PCR in nasopharynx | Mild | Anti-GD1b IgM positive | Spine: hyperintensity in posterior portion of the spinal cord from vertebral levels (C7–D1), no gadolinium enhancement |
| 13. Shahali et al. [75] | 63 | Male | DM, CRF, IHD | 4 days | Fever, fatigue, sore throat, and runny nose | Severe paraplegia, constipation, and urinary retention | ATM (LETM) | None | IVMP for 3 days and then tapered to 1 mg/kg/day), followed by IVIG (2.5 g daily for 3 days) | Complete resolution of neurologic manifestations | Positive PCR in nasopharynx | Moderate | IgG index = elevated (> 0.91) | Spine: LETM with linear enhancement within the mid and lower thoracic cord |
| 14. Chakraborty et al. [76] | 59 | Female | None | 4 days | Fever | Acute, severe progressive ascending flaccid paraplegia with retention of urine and constipation | ATM | None | IVMP at a dose of 1 g/day | Cardiac arrest, and death | Positive PCR in nasopharynx | Severe | NA | Thoracic spine: hyperintensity in the spinal cord at T6–T7 vertebral level, suggestive of myelitis |
| 15. Baghbanian et al. [77] | 53 | Female | DM, HTN, IHD | 14 days | Fever, respiratory symptoms | Paraplegia, low back pain and urinary incontinence | ATM (LETM) | None | PLEX | Partial recovery | Positive PCR in nasopharynx | Mild |
Negative CSF OCBs and the IgG index was in the upper limit of normal AQP4 and MOG antibodies were negative |
Spine: LETM in the T8–T10 cord segments Brain: normal |
| 16. Guler et al. [78] | 14 | Female | None | At initial presentation | Asymptomatic | Right hemiplegia | ATM (LETM) | None | IVIG was administered at 400 mg/kg/day for 5 days. Followed by IVMP was given at 30 mg/kg/day for 7 days | Partial improvement | Positive PCR in nasopharynx | Mild |
Serum AQP4 IgG was negative CSF OCBs were negative |
Spine: showed a contrast-enhancing lesion causing expansion at the C2–C5 level |
| 17. Fumery et al. [79] | 38 | Female | None | 14 days | Dry cough, myalgia, fatigue and shortness of breath | Paraplegia, hypoesthesia and bladder dysfunction | ATM (LETM) | None | IVMP (1 g daily for 8 consecutive days) | Significant clinical improvement | Positive PCR in nasopharynx | Mild |
Negative for OCBs and CSF SARS-CoV-2 PCR Negative MOG and AQP4 antibodies |
Spine: LETM with no gadolinium enhancement Brain: normal |
| 18. Nejad Bilgari et al. [80] | 11 | Female | None | 3 days | Fever | Flaccid paraplegia, urinary and fecal retention, epigastric pain | ATM (LETM) | None | IVIG (0.4 g/kg/day) for 5 days, IVMP (30 mg/kg) for 3 days, and seven sessions of PLEX | Slight improvement | Positive PCR in nasopharynx | Mild | NA |
Spinal: LETM Brain: normal |
| 19. Ali et al. [81] | 56 | Male | DM, G6PD deficiency | 3 days | Fever, fatigue, dyspnea | Flaccid paraplegia, urinary incontinence | ATM (LETM) | None | IV pulse steroids and acyclovir | No improvement, cardiac arrest, death | Positive PCR in nasopharynx | Moderate | NA |
Thoracic spine: LETM with no post-contrast enhancement Brain: normal |
| 20. Román et al. [82] | 72 | Male | HTN | None |
Asymptomatic Contact of a positive case |
Urine retention Dysesthesias in arms and legs and weakness of all four limbs |
ATM | None | IVMP (1 g/day) for 5 days, enoxaparin 40 mg daily, followed by IVIG (30 g/day) for five days. Oral prednisone was prescribed for the next 30 days | Partial improvement | Positive serology | Mild | Positive OCBs |
Brain: normal Cervicothoracic spinal: hyperintensities at C4–C5 and Th3–Th4 were observed without contrast enhancement |
| 21. Paterson et al. [3] | 48 | Male | DM, HTN | 19 days | Cough, dyspnea and fever | Numbness of hands and feet; band of itching sensation at level of the umbilicus and ataxia | Post-infectious myelitis (LETM) | None | IVMP for 3 days | Partial improvement | NA | Mild | Negative OCBs |
Brain: normal Thoracic spine: LETM down to the conus with no enhancement with contrast |
| 22. Saberi et al. [83] | 60 | Male | DM, HTN, hyperlipidemia | 2 weeks | Fever, nausea and vomiting | Progressive weakness of lower limbs accompanied by urinary incontinence and constipation | Post-infectious myelitis (LETM) | None |
IVIG (30 g/day) was initiated for 5 days PLEX for 5 days |
Improved initially then worsened again No improvement |
Negative PCR in nasopharynx | Mild | Negative AQP4 antibodies |
Cervical spine: LETM In the second cervical MRI, the previous hyperintense lesion was smaller and shrunken |
| 23. Lindan et al. [29] | 3 | Female | None | 1 day | Fever, diarrhea, urinary retention, hyperreflexia | Upper and lower extremity weakness, acute respiratory failures, confusion | Myelitis (LETM) | None | Supportive measures in ICU | No improvement | Positive PCR in nasopharynx | Severe | NA |
Brain: normal Spine: expansible T2-hyperintense signal from obex to mid-thoracic cord with mild enhancement Follow-up 4 days: worsening cord edema with extensive restricted diffusion, hemorrhage and enhancement Follow-up 3 weeks: interval myelomalacia with persistent restricted diffusion |
| 24. Lindan et al.29 | 12 | Male | None | 3 days | Fever, diarrhea | Urinary retention, hyperreflexia | Myelitis (LETM) | None | High-dose steroids | Partial improvement | Positive PCR in nasopharynx | NA | NA | Spine: long segment T2-hyperintensity from the obex through the mid-thoracic cord, with central predominance. No post-contrast imaging |
NP neurological presentation, NS nervous system, LETM longitudinally extensive transverse myelitis, PLEX plasma exchange, IVMP intravenous methyl prednisolone, IVIG intravenous immunoglobulin, OCBs oligoclonal bands, AQP4 Aquaporin4, MOG myelin oligodendrocyte glycoprotein, FUP follow-up, ANM acute necrotizing myelitis, CIS clinically isolated syndrome, PCR polymerase chain reaction, TM transverse myelitis, HTN hypertension, ATM acute transverse myelitis, DM diabetes mellitus, CRF chronic renal failure, IHD ischemic heart disease, G6PD glucose 6-phosphate dehydrogenase deficiency