Acute Necrotizing Myelitis in COVID-19

June 15, 2020 by Sam Bazzi

Adding to the macabre menagerie of potential complications from COVID-19, a new report published in Neurology: Neuroimmunology & Neuroinflammation describes acute necrotizing myelitis (ANM) associated with SARS-CoV-2 infection. A 69-year-old female patient from Spain presented to clinic with complaints of cervical pain, imbalance, and motor weakness/numbness in her left hand, which had persisted for one week. Her symptoms were preceded by fever and cough eight days prior to the onset of her neurological symptoms.

Her initial workup was negative for infections and autoimmune diseases and she was specifically ruled out for neuromyelitis optica (NMO) with a negative AQP4 and MOG IgG. On her CSF analysis, there were no oligoclonal bands, a typical marker of MS and other inflammatory disorders. Her CSF workup was also negative for bacterial or viral infection. CSF was positive for a mild lymphocytic pleocytosis (increased cell count) and high protein (2.83 g/L). The CSF was negative for SARS-CoV-2, though the nasopharyngeal swab was positive.

On review of imaging, the patient’s brain MRI was normal, but spinal cord images displayed an extensive T2-hyperintensity from medulla oblongata to C7, with evidence of acute transverse myelitis. IV Methylprednisolone was given for 5 days and led to initial improvement, though the patient proceeded to rapidly deteriorate following cessation of methylprednisolone. She developed sensory motor deficits in her hands and paraparesis with bowel incontinence. One week after admission, a follow up MRI revealed extension of the myelitis to T6 with associated enhancement and a new focal necrotizing area at T1 with peripheral enhancement. Following her clinical deterioration, the patient was treated with plasma exchange and another course of methylprednisolone pulse for 5 days, in addition to slow oral administration of prednisone, which ultimately resulted in improvement of her motor function. The patient continued to improve over the course of the next four weeks and was able to walk with assistance as well as write and use her mobile phone (though with some difficulty). Persistent issues that did not resolve at the time of writing this paper were weakness in the left leg and lack of bowel control. An MRI done post plasmapheresis revealed a decrease in myelitis extension and enhancement, but unchanged central necrosis.

The authors diagnosed her with acute necrotizing myelitis (ANM), which is rare and has been previously associated with NMO and other inflammatory diseases. The association of ANM with COVID-19 has not been studied, but it is hypothesized that ANM appears as a result of the cytokine storm secondary to viral infection. The authors also hypothesized that these neurological symptoms could be due to the neuroinvasive potential of SARS-CoV-2, which is a topic I have described in previous blog posts. This study is also similar to case studies describing COVID-associated acute necrotizing encephalitis (ANE). So far, these cases of ANE and ANM appear to be exceedingly rare complications that affect elderly patients, but not much is known about how they develop or what aspect of aging confers higher risk of developing these frightening neurological symptoms.

Written by: Sam Bazzi
Edited by: Jina Zhou and Esther Melamed
6/15/2020