To the Editor:
We read with interest the article by Eom et al.1 about two patients, an 81 years old male (patient-1) and a 23 years old female (patient-2), who developed transverse myelitis three days (patient-1) respectively 21 days (patient-2) following the second (patient-2) respectively first dose of the Biontech Pfizer vaccine (BPV). Patient-1 presented with distal weakness, sensory disturbances and spasticity of the upper limbs.1 Patient-2 presented with paraparesis and sensory disturbances of the lower limbs and urinary retention.1 Spinal MRI revealed a T2-hyperintense lesion C1-C3 (patient-1) and a T2-hyperintense lesion in the conus medullaris (patient-2).1 Both patients received steroids but recovery was incomplete at the one month (patient-1) respectively 3 months (patient-2) follow-up.1 The study is appealing but raises concerns that need to be discussed.
We disagree that transverse myelitis is a rare complication of SARS-CoV-2 vaccinations.1 When reviewing the literature about transverse myelitis following a SARS-CoV-2 vaccination, 24 cases were identified of whom detailed individual data were available from 20 patients (Table 1). Age of these 20 patients ranged between 23 and 85 years. Twelve of these patients were female and eight were male (Table 1). Vaccine brands applied were the BPV (n = 7), the Astra Zeneca vaccine (AZV, n = 9), the Moderan vaccine (MOV, n = 2), the Johnson and Johnson vaccine (JJV, n = 1), and the Sinovac vaccine (SVV, n = 1) (Table 1). Latency between vaccination and onset of clinical manifestations of transverse myelitis ranged from one day to 21 days (Table 1). Patients were treated with steroids (n = 20, plasma exchange (n = 4), or immune-adsorption (n = 1) (Table 1). The outcome at the last follow up was reported as complete recovery in three patients, as incomplete recovery in 16 patients, and as fatal in one patient (Table 1). This case series does not include those with myelin oligodendrocyte glycoprotein (MOG)-associated myelitis, neuromyelitis optica spectrum disorder (NMO-SD), those with acute disseminated encephalomyelitis (ADEM), or those with a spinal relapse of multiple sclerosis as complications of a SARS-CoV-2 vaccination. Since not all patients with post-SARS-CoV-2 vaccination transverse myelitis have been published, it is conceivable that the true number of patients with COVID vaccination associated myelitis is much higher.
Table 1. Patients reported as per the end of March 2022 in whom SARS-CoV-2 vaccination was complicated by transverse myelitis (modified according to Finsterer, Hum Vaccine Immunother 2022).
| Age | Sex | Brand | LVOTM (d) | Treatment | OCLFU | Reference |
|---|---|---|---|---|---|---|
| 23 | F | BPV | 21 | ST | IR | Eom 2022 |
| 81 | M | BPV | 3 | ST | IR | Eom 2022 |
| 26 | F | BPV | 2 | ST | IR | Fernandes 2022 |
| 31 | F | 1. AZV | 21 | ST | IR | Maroufi 2022 |
| 75 | M | BPV | 3 | ST | IR | Miyaue 2022 |
| 40 | F | AZV | 14 | ST, PE, IA | IR | Helmchen 2022 |
| 26 | F | 1. BPV | 3 | ST | IR | Alkabal 2021 |
| 85 | M | BPV | 1 | ST | FO | Nakano 2021 |
| 36 | M | AZV | 8 | ST | CR | Malhotra 2021 |
| 63 | M | MOV | 2 | ST | CR | Fitzsimmons 2021 |
| 45 | M | AZV | 8 | ST | IR | Pagenkopf 2021 |
| 41 | M | AZV | 14 | ST | IR | Hsiao 2021 |
| 25 | F | AZV | 16 | ST | IR | Tan 2021 |
| 76 | F | MOV | 6 | ST | IR | Gao 2021 |
| 58 | M | AZV | 10 | ST, PE | IR | Nothgi 2021 |
| 67 | F | MOV | 1 | ST, PE | IR | Khan 2022 |
| 44 | F | JJV | 7 | ST, PE | IR | Tahir 2021 |
| 78 | F | SVV | 3 | ST | ÎR | Erdem 2021 |
| Nr | nr | AZV | nr | nr | nr | VAERS |
| 69 | F | 1. BPV | 2 | ST | IR | McLean 2021 |
| 44 | F | 1. AZV | 4 | ST | CR | Vegezzi 2021 |
| N = 3 | nr | AZV | nr | nr | nr | Knoll 2021 |
AZV = Astra Zeneca vaccine, BPV = Biontech Pfizer vaccine, CR = complete recovery, FO = fatal outcome, IA = immune adsorption, IR = incomplete recovery, JJV = Johnson and Johnson vaccine, LVOTM = latency between vaccination and onset of transverse myelitis, MOV = Moderna vaccine, OCLFU = outcome at last follow-up, PE = plasma exchange, ST = steroids, SVV = Sinovac vaccine, nr = not reported.
Overall, the interesting study has limitations which challenge the results and their interpretation. Addressing these issues would strengthen the conclusions and could be more educative. Myelitis as a complication of SARS-CoV-2 vaccinations is not infrequent and treating physicians should be aware of this side effect to diagnose patients thoroughly and treat them adequately in due time.
Footnotes
Disclosure: The author has no potential conflicts of interest to disclose.
References
- 1.Eom H, Kim SW, Kim M, Kim YE, Kim JH, Shin HY, et al. Case Reports of acute transverse myelitis associated with mRNA vaccine for COVID-19. J Korean Med Sci. 2022;37(7):e52. doi: 10.3346/jkms.2022.37.e52. [DOI] [PMC free article] [PubMed] [Google Scholar]