A 47 year old man was admitted to the emergency room with paraplegia since 6 hours ago. His earliest symptoms was urinary retention that started 12 hours before lower limbs weakness. The paraplegia occurred abruptly and was accompanied with a dull pain in the flanks and abdomen that subsided 1-2 hours later. The patient also reported decreased sensation of lower limbs and torso. He denied any symptoms in upper limbs. 10 days before the onset of paraplegia, the patient had fever, cough and diarrhea. He was diagnosed with COVID-19 and was quarantined at home. He had no past medical history.
On physical examination the patient was afebrile with respiratory rate of 15/minute, and oxygen saturation of 98% on room air. Initial neurological examination revealed intact cranial nerves, and lower limbs weakness with medical research council(MRC) score of 0/5 in proximal and distal. Lower limbs were flaccid and had absent deep tendon reflexes. Sensory examination showed decreased sensation of all modalities in lower limbs with a sensory level at T10. Plantar reflexes were neutral and abdominal reflex was also absent. Motor and sensory and cerebellar examination of upper limbs was normal.
Nasopharyngeal swab test for severe acute respiratory syndrome coronavirus 2(SARS-COV-2) polymerase chain reaction(PCR) was positive, SARS-COV-2 serology was as follows: IgM:11.72 IU/ml(>1.1 positive), IgG:18.31 IU/ml(>1.1 positive). Whole spinal magnetic resonance imaging(MRI) was performed that revealed a longitudinal extensive myelitis(LETM) involving second cervical to second thoracic segment of spine.(figure 1) The lesion had gadolinium enhancement. Lumbar puncture was performed with glucose:60 mg/dl, protein:110 mg/dl and white blood cell: 650(80% polymorphonuclear cells and 20% mononuclear cells). Gram stain, culture, herpes zoster, varicella zoster and Epstein-Barr virus (EBV) serology of cerebrospinal fluid(CSF) returned negative. Patient’s serum Aquaporin-4 antibody was also negative. Autoimmune immunological screening including Lupus anticoagulant, Protein S and C levels, Anti-Neutrophil Cytoplasmic antibodies, Rheumatoid fac- tor, Anti Cardiolipin, and Anti Beta 2 Glycoprotein were all negative. The patient was diagnosed with COVID-19 associated transverse myelitis but infectious etiology was still kept in mind due to patient’s CSF analysis.
Treatment was started with parenteral antibiotics(ceftriaxone and vancomycin), acyclovir and 5 sessions of plasma exchange. Unfortunately the patient had no response to treatment and was discharged to a rehabilitation center.
The patient was disappointed with the treatment we provided. He felt no improvement and wanted us to further treat him with plasma exchange. Although he was cooperative in his rehabilitation session, at the end of his hospital stay, he felt hopeless.