key: cord-0695345-qf5ofia6
authors: Barman, Apurba; Sahoo, Jagannatha; Viswanath, Amrutha; Roy, Sankha Subhra; Swarnakar, Raktim; Bhattacharjee, Souvik
title: Clinical Features, Laboratory, and Radiological Findings of Patients With Acute Inflammatory Myelopathy After COVID-19 Infection: A Narrative Review
date: 2021-08-04
journal: Am J Phys Med Rehabil
DOI: 10.1097/phm.0000000000001857
sha: 803af0b928cd960de91215879220239d2018f66b
doc_id: 695345
cord_uid: qf5ofia6

The objective of this review was to analyze the existing data on acute inflammatory myelopathies associated with coronavirus disease 2019 infection, which were reported globally in 2020. PubMed, CENTRAL, MEDLINE, and online publication databases were searched. Thirty-three acute inflammatory myelopathy cases (among them, seven cases had associated brain lesions) associated with coronavirus disease 2019 infection were reported. Demyelinating change was seen in cervical and thoracic regions (27.3% each, separately). Simultaneous involvement of both regions, cervical and thoracic, was seen in 45.4% of the patients. Most acute inflammatory myelopathy disorders reported sensory motor and bowel bladder dysfunctions. On cerebrospinal fluid analysis, pleocytosis and increased protein were reported in 56.7% and 76.7% of the patients, respectively. Cerebrospinal fluid severe acute respiratory syndrome coronavirus 2 reverse transcriptase–polymerase chain reaction was positive in five patients. On T2-weighted imaging, longitudinally extensive transverse myelitis and short-segment demyelinating lesions were reported in 76% and 21%, respectively. Among the patients with longitudinally extensive transverse myelitis, 61% reported “moderate to significant” improvement and 26% demonstrated “no improvement” in the motor function of lower limbs. Demyelinating changes in the entire spinal cord were observed in three patients. Most of the patients with acute inflammatory myelopathy (including brain lesions) were treated with methylprednisolone (81.8%) and plasma-exchange therapy (42.4%). An early treatment, especially with intravenous methylprednisolone with or without immunoglobulin and plasma-exchange therapy, helped improve motor recovery in the patients with acute inflammatory myelopathy associated with coronavirus disease 2019.

C oronavirus disease 2019 (COVID-19) is mainly a respiratory disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 1 Recently, many studies have shown that SARS-CoV-2 virus infection can also affect multiple organ systems of the body, including the central nervous system. 2 Acute inflammatory myelopathy (AIM) is a heterogeneous group of inflammatory spinal cord disorders, which includes multiple demyelinating conditions of the spine, like acute transverse myelitis (ATM), neuromyelitis optica (NMO), acute disseminated encephalomyelitis (ADEM), multiple sclerosis, and clinically isolated syndrome. 3 Acute transverse myelitis is an immune-mediated central nervous system disorder that primarily affects the spinothalamic and pyramidal tracts, posterior columns, and the anterior funiculus of the spinal cord at one or more levels. 4 Longitudinally extensive transverse myelitis (LETM) is a variant of ATM, where inflammatory (demyelinating) lesions extend over three or more vertebral segments. 5 Longitudinally extensive transverse myelitis is associated with NMO and ADEM, 5 whereas short-segment demyelinating lesions are usually seen in multiple sclerosis and clinically isolated syndrome. Neuromyelitis optica is an inflammatory demyelinating condition, which involves the optic nerve along with the spinal cord. 5, 6 Acute disseminated encephalomyelitis results in diffuse demyelination of the cerebral white matter along with the involvement of the spinal cord. 7 Magnetic resonance imaging (MRI) is essential in evaluating AIM, especially to visualize the intraparenchymal spinal lesions and differentiate them from other compressive and noncompressive spinal lesions. 3, 7, 8 Radiologically, AIM is characterized by enhancement of the lesions (demyelinating) after contrast (gadolinium) administration. 5, 9 Acute inflammatory myelopathies and their different variants have a very unpredictable disease course. 3, 7 If diagnosed, treated, and rehabilitated early, patients with AIM can significantly improve functional outcomes. 8 The purpose of this review is to provide a synopsis of the information regarding the clinical features, including laboratory findings, neuroimaging findings, and acute management and treatment outcomes of patients with AIM after COVID-19 infection. To determine the short-and long-term rehabilitation goals for these patients, especially at admission, it is essential for the rehabilitation physician to know about their clinical features, laboratory, neuroimaging findings, acute management, and expected outcome.

The review was performed according to the PRISMA-P 2015 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. 10 

Titles and abstracts of the retrieved studies were screened by two reviewers (AB, AV) independently and were identified as included, excluded, or uncertain. In case of uncertainty, the full-text article was obtained and reviewed for eligibility based on inclusion criteria. Any discrepancies during the selection were resolved by discussion and consensus.

Depending on the improvement of motor power or function of the bilateral lower limbs, motor recovery of a patient was categorized into (1) "moderate to significant" improvement, (2) "marginal to a slight" improvement, and (3) "no improvement." Motor recovery was reported as "moderate to significant" improvement if the study reported either (a) moderate to significant improvement of motor function in lower limbs, or (b) improvement in muscle power more than one grade on the Medical Research Council scale for muscle strength, or (c) the affected patient has progressed to "walking with or without support" from "nonambulant" condition. Motor recovery was categorized into "marginal to slight" improvement if the study reported that (a) there is minimal/marginal to slight improvement or (b) improvement in muscle power of affected lower limb one grade or less on the Medical Research Council scale. The motor recovery was classified as "no improvement" if it mentioned no lower limb muscle power improvement.

Motor recovery/neurological outcome from the included study was assessed at the end of treatment or at the time of follow-up visit, whichever was later.

Two reviewers (AB and SR) extracted the data independently with a standardized data collection form, including (1) demographic characteristics (age and sex); (2) basic information regarding COVID-19 infection; (3) clinical symptoms related to myelopathy; (4) autoimmune profiles, viral markers, and cerebrospinal fluid (CSF) analysis; (5) MRI findings; (6) acute management; and (7) neurological outcomes or motor recovery.

Data were presented with descriptive statistics. Any discrepancies in data acquisition or interpretation were resolved during the data extraction process through discussion or consultation with the third reviewer (JS). The total number of events and participants was extracted for dichotomous outcomes. For continuous outcomes, data were presented in mean (SD). If mean and SD were not reported in the particular study, it was calculated manually from the reported indicators. If data were not available or written in an unusable way, the specific research was excluded from analysis, and then, the data were presented descriptively.

A total of 4051 articles were identified from electronic databases. After removing duplicate and irrelevant (not matching the inclusion and exclusion criteria) articles, 31 case reports (33 patients) with AIM were included in this review. Among them (N = 33), 26 patients (24 case reports) 38, 40, 41 had only spinal cord involvement with no brain involvement. Seven cases had both spinal cord and brain involvement. [32] [33] [34] [35] [36] [37] 39 The PRISMA flow diagram, including the reasons for excluding studies, is presented in Figure 1 .

Thirty-three patients fulfilled the inclusion criteria (Table 1) . All patients (N = 33) were admitted and treated at an acute care hospital. Two patients 15, 29 received inpatient rehabilitation after discharge. The mean (SD) age of the included patients was 47 (17.7) yrs. The youngest patient was a 3-yr-old female child. 16 The male-to-female ratio was 16:17.

Of the 33 patients 11-41 with AIM, 82% (n = 27) [11] [12] [13] [14] [15] [17] [18] [19] [20] [22] [23] [24] [25] [26] [27] [30] [31] [32] [33] [35] [36] [37] [38] [39] [40] [41] presented with COVID-associated symptoms (cough, fever, dyspnea, myalgia, fatigue, chills, anosmia, and rhinorrhea). The latency period (mean time between the onset of COVID-19 infection to first symptom of inflammatory myelopathy) of AIM varied from 2 days 22 to 3 wks. 31, 33 Six patients 16, 21, 26, 28, 29, 34 did not report any COVID-19 symptoms previously, presented directly with neurological symptoms (either urinary symptoms or sudden weakness).

Autoimmune profiles, viral markers, and CSF analysis were done in all cases. Laboratory findings (autoimmune profiles, viral markers, and CSF analysis) of these patients (N = 33) are presented in Table 1 . The CSF analysis was done in 30 cases. Five patients 16, 23, 30, 34, 35 (17%) were CSF SARS-CoV-2 RT-PCR positive.

Detailed neuroimaging findings of each patient are presented in Table 1 . On MRI of the spine, nine patients had demyelinating changes in the "cervical region only." 18, [26] [27] [28] [30] [31] [32] 35, 36 Demyelinating change in "thoracic region only" was seen in nine patients. [11] [12] [13] 17, [19] [20] [21] 25, 33 Simultaneous and/or overlapping involvement of both regions, "cervical and thoracic," were seen in 15 patients. [14] [15] [16] [22] [23] [24] [25] [26] 29, 34, [37] [38] [39] [40] [41] Based on the length of the longitudinal (demyelinating) lesions, it was categorized into two groups. An LETM (lesions extending ≥3 vertebral segments) were seen in 25 patients (76%) 11, 12, [14] [15] [16] [17] [18] [19] [20] [22] [23] [24] [25] [26] [27] [28] 30, 32, 34, [37] [38] [39] [40] [41] and short-segment spinal demyelinating lesions (lesions extending <3 vertebral segments) were seen in 7 patients (21%). 13, 21, 24, 29, 31, 33, 36 Extent (exact length) of spinal (cervical) segment involvement (demyelination) was not reported in one patient. 35 Among the patients with LETM lesions (n = 25), demyelinating lesions in the entire spinal cord (upper cervical to conus) were seen in three patients. 14, 15, 40 Clinical, Laboratory, and Radiological Findings and Outcome of Patients With "AIM Without Any Brain Lesion"

The group, "AIM without any brain lesion," includes 26 patients (3-70 yrs of age). 38, 40, 41 The clinical features of these 26 patients are summarized in Table 1 .

Motor deficits in lower limbs were reported in 23 patients (88.5%). [11] [12] [13] [15] [16] [17] [18] [19] [20] [22] [23] [24] [25] [26] [27] [28] [29] [30] 38, 40, 41 One had hemiplegia, 28 and 22 had motor deficits in both lower limbs (symmetrical involvement). The evolution of paralysis varied from patient to patient, from abrupt onset (few hours) 25,26,28 to 7 days. 18 Sensory deficits (abnormal sensation) were reported in 21 patients. [11] [12] [13] [14] [15] 18, 19, 21, [23] [24] [25] [26] [27] [28] [29] 31, 38, 40, 41 Definite clear sensory level (sensory loss below particular level) was reported in 66.7% of the patients, [11] [12] [13] [14] [23] [24] [25] [26] [27] 29, 38, 40, 41 whereas altered sensations (in form of tingling, numbness, and/or paraesthesia but without sensory level) were reported in 33.3% of the patients. 15, 18, 19, 21, 26, 28, 31 Six patients 12, 14, 17, 23, 25, 26 reported low back pain.

Bowel bladder dysfunctions were reported in 23 patients. [11] [12] [13] [14] [15] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] 29, 30, 38, 40, 41 Common bladder dysfunctions were urinary retention, urinary overflow incontinence, and urinary urgency (Table 1) .

Two patients 14, 21 presented with sensory and bladder involvement but without any motor involvement.

Laboratory Findings (AIM Without Any Brain Lesion) 

Motor recovery: "no improvement" Outcome assessment: NR 18 patients (Table 1) . Cells (white blood cells) were not detected in CSF of four patients. 26, [28] [29] [30] 38 Protein amount was normal in three patients. 24, 26, 38 Oligoclonal bands (OCBs) were identified in three patients. 24, 26, 33 Two patients were SARS-CoV-2 RT-PCR positive. 16, 31 Radiological Findings (AIM Without Any Brain Lesion)

Eight patients (30.8%) [11] [12] [13] 17, [19] [20] [21] 25 presented demyelinating changes in "thoracic region only." Demyelinating change in "cervical region only" was seen in six patients (23.1%). 18, [26] [27] [28] 30, 31 Another 12 patients (46.1%) [14] [15] [16] [22] [23] [24] [25] [26] 29, 38, 40, 41 showed demyelinating changes in both the cervical and thoracic regions.

Radiological details of each patient are presented in Table 1 . The mean length of the spinal lesion (signal changes) was 6.15 segments (vertebrae). Longitudinally extensive transverse myelitis (≥3 vertebral segments) was detected in 22 patients (84.6%). 11, 12, [14] [15] [16] [17] [18] [19] [20] 22, 23, [25] [26] [27] [28] 30, 38, 40, 41 Among them (n = 22), three had demyelinating changes in the entire spinal cord. 14, 15, 40 Treatment Outcome (AIM Without Any Brain Lesion)

Sixty-seven percent of the patients 11, [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] 25, 26, [28] [29] [30] 38, 40, 41 were treated with intravenous (IV) methylprednisolone (MPS), 39% 12, [14] [15] [16] 18, [24] [25] [26] 30, 38, 40, 41 with plasma-exchange therapy (PLEX), and 21% 16, [23] [24] [25] [28] [29] [30] were treated with IV immunoglobulin. Antiviral medications were given to 27% of the patients (n = 7). 11, 17, 22, 23, 26, 30, 40 After acute hospital treatment, 42.3% of the patients (n = 11) had "moderate to significant" improvement 11, [18] [19] [20] 22, 23, [26] [27] [28] 38, 41 and 18.2% (n = 2) had "marginal to slight" improvement 12, 24 in lower limb motor functions. Seven patients (27%) 15, 16, 25, 26, 29, 30, 40 did not report any improvement in lower limb motor function.

Among the patients with LETM (n = 21), 20 reported motor deficits in lower limbs. One patient 14 (with LETM) did not report any kind of motor deficit in the lower limb. Of the 20 patients with motor deficits, two died. After acute treatment, "moderate to significant" improvement in lower limb motor function was seen in 55% of the patients, and "marginal to slight" improvement was seen in one patient. Six patients (30%) did not report any improvement in lower limbs.

Short-segment demyelinating changes were seen in five patients. 13, 21, 24, 29, 31 Among them (n = 5), three 13, 24, 29 reported motor deficits in the lower limb, and two did not report any motor deficits. Among the three patients with motor deficits, one death 13 was reported and one showed "marginal to slight" improvement in the lower limb. 24 One patient 29 did not report improvement in the lower limb.

Clinical, Laboratory, and Radiological Findings and Treatment Outcome of Patients With "AIM With a Brain Lesion"

The group, "AIM with a brain lesion," included seven patients [32] [33] [34] [35] [36] [37] 39 (male/female: 5/2) with a mean age of 46.6 (12.74) yrs. Clinical features of these patients are summarized in Table 1 . [32] [33] [34] [35] [36] 39 Bowel bladder dysfunction was seen in 42.8% of the patients. 32, 34, 39 Visual impairment was seen in two patients. 33, 36 One patient reported episodes of seizure. 37 

On CSF analysis, four patients [32] [33] [34] 39 had pleocytosis and five had elevated protein. [32] [33] [34] [35] 39 Oligoclonal bands were seen in one patient. 33 Two patients were SARS-CoV-2 RT-PCR positive. 34, 35 Anti-SARS-CoV-2 immunoglobulin G (IgG) antibody was detected in one patient. 33 

Among the patients with "AIM with a brain lesion," LETM was seen in four patients, 32, 34, 37, 39 and short-segment demyelinating lesion was found in two patients. 33, 36 Extent (exact length) of the demyelinating lesion (in cervical region) was not reported in one patient. 35 

Five patients [33] [34] [35] 37, 39 were treated with MPS, One 39 with PLEX and two 33, 34 were treated with IV immunoglobulin treatment. Three patients 32,35,37 received antiviral medications.

No deaths were reported in patients with "AIM with a brain lesion." After receiving treatments, all patients (including patients with motor deficits) reported "moderate to significant improvement."

This review suggests that the SARS-CoV-2 virus, like other viral diseases 28 (eg, Herpesviridae, Flaviviridae, Paramyxoviridae, Orthomyxoviridae), can affect the spinal cord and can result in AIM. In 2020, 33 cases of AIM (7 patients with brain and spinal cord involvement) had been reported after SARS-CoV-2 infection.

The exact mechanism of spinal cord involvement after COVID-19 infection has not yet been determined. However, it has been suggested that SARS-CoV-2 can damage the spinal cord through the angiotensin-converting enzyme (ACE) 2 receptors present in the cell surface 23, 26, 29 or through the mechanism of cytokine storm or post-infectious inflammatory or immune-mediated mechanism. 13, 23, 29, 42, 43 A significant number of cases (86.4%) 11,12,14,15,18-20,24-27, 30-33,36,39,41 in this review reported a longer latency period (≥7 days), which suggests post-infective immunological disorder is likely the cause of spinal cord damage. It has been postulated that the altered immune response (immune reaction against the agent), due to an imbalance between the proinflammatory and anti-inflammatory cytokines in COVID-19, initiates the demyelinating process silently in genetically susceptible persons. 40, 43 Cytokine storm is the proinflammatory state characterized by increased release of interleukin 1, interleukin 6, and tumor necrosis factor α. 12, 43 It is a well-known complication of COVID-19 infection and can cause activation of the glial cells with subsequent demyelination of the spinal cord. [42] [43] [44] Late and insufficient release of the interferons (interferon α and interferon β) in COVID-19 infection further facilitates the spread of the virus in the human body. 40, 43 Acute inflammatory myelopathies usually, at their peak, cause paraplegia (50%), bladder dysfunction (100%), and sensory deficits (80%-94%). 45 In this review, we also observed similar findings. Besides this, we also found six patients, 12, 14, 17, 23, 25, 26 with low back pain, two with visual problems, 33, 36 and one patient 37 with episodes of seizure.

Lymphocytic pleocytosis and increased protein count in CSF have been reported as essential characteristics of acute inflammation of the spinal cord. 7 However, in CSF study, cell counts and protein amount can be found normal in few subsets of AIMs (e.g., multiple sclerosis and ADEM). 5 In this review, we observed pleocytosis and increased protein count in 56.7% and 76.7% of the patients, respectively.

Similar to the observations, 8 made by many of the included studies, 14, 31, 33, [35] [36] [37] this review also could not find any specific relationship with the neurological level of injury (sensory and/ or motor level, on clinical examination) and site of lesions, seen on MRI (at the time of admission). Even in patients with AIM who had a weakness, their neurological levels (sensory and/or motor level) did not match their radiological lesions (on MRI spine). Therefore, it is essential to have MRI screening of the entire spine and brain irrespective of their neurological level (sensory and/or motor level) if they are suspected of inflammatory myelopathy. This review observed two patients with LETM 14,37 and four patients with short-segment demyelination at the spinal cord, 31, 33, 35, 36 which had not presented with the typical acute symptom onset of motor weakness.

Cree 9 identified several clinical features, which could predict a better prognosis after AIM. These favorable factors included older age at symptom onset, hyperreflexia, and posterior column sensation, Babinski signs at the peak of the deficit. In this review, we found 10 patients with hyperreflexia 11, 18, 19, 24, 26, 27, 29, 33, 38, 41 during the peak of the attack; among them, eight patients (80.0%) 11, 18, 19, 26, 27, 33, 38, 41 improved significantly ("moderate to significant improvement") in motor function.

In the treatment of AIM, several drugs have been tried to reduce spinal cord inflammation and prevent further damage to the spinal cord. These drugs included IV-MPS, plasma-exchange therapy, immunosuppressive drugs like cyclophosphamide, azathioprine, immunoglobulin, and treatment with monoclonal antibody rituximab. 46 Of all medications, IV-MPS is used most frequently in these cases, especially immediately after diagnosis. 8, 46 In this review, 13 patients (50%, of 26) reported significant motor recovery in both lower limbs after corticosteroid/MPS injection. Similar to our observation, many studies 47-51 reported significant motor improvement after MPS therapy.

Patients with AIM usually experience multiple disabilities, including motor deficits, sensory impairments, bowel bladder dysfunction, and sexual problems. Many studies 8, 52, 53 have reported significant functional recovery after inpatient rehabilitation. After an acute attack of inflammatory myelopathy, one third of patients achieve almost full motor recovery, one third experience a moderate degree of permanent disability, and one third of patients fail to improve (severe disability) or do not survive. 7, 45 Patients who eventually achieve full motor recovery (100%) can have persistent bladder dysfunction (50%-86%), bowel deficits (36%-77%), and sexual dysfunction (82%). 54 However, it has to be remembered that these data have come from patients of AIMs due to non-COVID etiologies. Comprehensive multidisciplinary rehabilitation is of paramount importance for patients with AIM. Based on our review, similar clinical findings and rehabilitation needs are present in the COVID-associated AIM population. These issues usually include management of spasticity, pain, paraesthesia, fatigue, motor deficits, bowel bladder, and sexual dysfunctions. 46 Previous data suggest that irrespective of the etiological factors, the chances of recurrences (neurological deficits) after AIM are very high (17.5%-61%). 46 Therefore, it is essential to monitor neurological status, inflammatory, and infective markers regularly, especially if it is diagnosed as a postinfective complication of COVID-19.

This review has several limitations. First of all, this review included only case reports. Therefore, unintentional biases are inherent in the selection and interpretation of case series. Second, there was no uniformity in reporting the clinical features of motor weakness, bowel bladder dysfunction, and functional outcomes. Third, this series could not document the severity of sensory, motor, and functional deficits after AIM as there was no standardized data. Based on motor recovery of bilateral lower limbs, the neurological outcome was assessed. No standardized functional assessment scale was used. Finally, there was no definite duration of the follow-up period or outcome assessment. The outcome assessment period varied between 6 days to 2 mos. Besides these, the majority of the included patients were assessed before initiating comprehensive neurorehabilitation. Although few cases reported that their cases received physical and occupational therapy management, details of rehabilitation management during the hospital stay and at follow-up visits were not available. Thus, details on the need for rehabilitation strategies, length of stay in rehabilitation hospitals, discharge facilities, and postinjury complications could not be discussed.

Moreover, one of the essential aspects of outcomes of COVID-19-associated AIM is the quality of life and mental health, and there were no data on these issues. Despite these shortcomings, the present organized review will act as a preliminary guide for clinicians while dealing with suspected cases of SARS-CoV-2 infection-associated AIM. In addition, these data can increase international curiosity as it can be compared with previously published results in the pre-COVID-19 era.

The SARS-CoV-2 virus has the potential to affect the central nervous system and can cause AIM. However, COVIDassociated AIM may or may not be associated with a brain lesion. Like other myelopathies, reported cases of COVID-related AIM include sensory motor and bowel bladder dysfunctions. Acute inflammatory myelopathy associated with COVID-19 infection can range from involving a short segment to an extensive demyelinating spinal cord lesion. Lymphocytic pleocytosis Barman et al.

Volume 100, Number 10, October 2021 and increased protein are the commonly found abnormal parameters in CSF analysis. Early treatment with IV MPS has shown improved outcomes in patients with AIM. This study is only a preliminary review of AIM, which can be stated as an additional cause of functional loss after COVID-19 infection. We have identified the need for further research on the outcome and success of rehabilitation in these patients on detailed analysis. Further studies with a large population having received comprehensive, holistic rehabilitation, and long-term follow-up are required to determine the exact prognosis of patients with AIM associated with COVID-19 infection.

A novel coronavirus from patients with pneumonia in China

The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings

Etiologic spectrum and functional outcome of the acute inflammatory myelitis

Acute transverse myelitis. A localized form of postinfectious encephalomyelitis

The differential diagnosis of longitudinally extensive transverse myelitis

Neuromyelitis optica IgG predicts relapse after longitudinally extensive transverse myelitis

Diagnostic approach to myelopathies

Neurological and functional recovery in acute transverse myelitis patients with inpatient rehabilitation and magnetic resonance imaging correlates

Acute inflammatory myelopathies

PRISMA-P Group: Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement

Acute transverse myelitis after COVID-19 pneumonia

Post COVID-19 longitudinally extensive transverse myelitis (LETM)-a case report

COVID-19-associated acute transverse myelitis: a rare entity

A case report of acute transverse myelitis following novel coronavirus infection

Acute transverse myelitis associated with SARS-CoV-2: a case-report

Transverse myelitis in a child with COVID-19

Acute flaccid myelitis in COVID-19

COVID-19-associated acute necrotizing myelitis

Acute transverse myelitis in COVID-19 infection

Acute transverse myelitis secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): a case report

Para-infectious anti-GD2/GD3 IgM myelitis during the COVID-19 pandemic: case report and literature review

Acute myelitis as a neurological complication of COVID-19: a case report and MRI findings

Acute transverse myelitis after SARS-CoV-2 infection: a rare complicated case of rapid onset paraplegia in a male veteran

A rare case of acute motor axonal neuropathy and myelitis related to SARS-CoV-2 infection

Case report: acute spinal cord myelopathy in patients with COVID-19

Transverse myelitis in COVID-19 patients: report of two cases

Longitudinally extensive transverse myelitis following acute COVID-19 infection

Acute myelitis secondary to COVID-19 in an adolescent: causality or coincidence? New trends

SARS-CoV-2-associated acute transverse myelitis in panama with analysis of 38 cases reported worldwide during COVID-19

COVID-19-associated myelitis, para/post infectious or infectious myelitis: a case report from the North of Iran

First case of SARS-COV-2 sequencing in cerebrospinal fluid of a patient with suspected demyelinating disease

A case of possible atypical demyelinating event of the central nervous system following COVID-19

Acute disseminated encephalomyelitis after SARS-CoV-2 infection

Possible acute disseminated encephalomyelitis related to severe acute respiratory syndrome coronavirus 2 infection

Encephalomyelitis associated with COVID-19 infection: case report

Lessons of the month 1: a case of rhombencephalitis as a rare complication of acute COVID-19 infection

SARS-CoV-2 can induce brain and spine demyelinating lesions

Acute transverse myelitis in a HIV-positive patient with COVID-19

COVID-19 associated with encephalomyeloradiculitis and positive anti-aquaporin-4 antibodies: cause or coincidence?

COVID-19 infection-induced neuromyelitis optica: a case report

RETRACTED ARTICLE: Acute necrotizing myelitis and acute motor axonal neuropathy in a COVID-19 patient

Cytokine storms in COVID-19 cases?

The pathogenesis and treatment of the 'cytokine storm' in COVID-19

Cytokine storm in COVID-19: the current evidence and treatment strategies

Demyelinating disorders: update on transverse myelitis

Transverse myelitis

Acute transverse myelopathy in childhood

Acquired transverse myelopathy in children in the United Kingdom-a 2 year prospective study

Efficacy of high dose steroid therapy in children with severe acute transverse myelitis

MRI findings in acute idiopathic transverse myelopathy in children

Etiologic spectrum and prognosis in noncompressive acute transverse myelopathies: an experience of 80 patients at a tertiary care facility

Non-traumatic spinal cord lesions: epidemiology, complications, neurological and functional outcome of rehabilitation

Long-term outcome of acute and subacute myelopathies

Transverse myelitis in children: long-term urological outcomes

Volume 100, Number 10, October 2021Acute Inflammatory Myelopathy After COVID-19