key: cord-0732520-41er6aa4
authors: J, Guarnaccia; M, Creed; S, Muriel
title: Transverse myelitis as a First Event of Multiple Sclerosis Precipitated by Pfizer-BioNTech COVID-19 vaccination
date: 2022-02-04
journal: Neuroimmunology Reports
DOI: 10.1016/j.nerep.2022.100074
sha: 84d067cd75da599e74d5c22e7095e6f324365e27
doc_id: 732520
cord_uid: 41er6aa4

Background : Neurological complications from COVID-19 vaccines are rare Case Report : Herein, we present the case of a previously healthy woman who developed incomplete transverse myelitis (TM) immediately after receiving her first injection of the Pfizer-BioNTech Covid-19 vaccine. Conclusion : This case is an example of TM as a first clinical event in the diagnosis of multiple sclerosis triggered by COVID-19 vaccination. A review of the the FDA's Vaccine Adverse Event Reporting System (VAERS) reveals similar instances of TM. Clinicians should be aware of this potential complication from COVID-19 vaccination.

Myelitis is a known, rare complication of several vaccines, including hepatitis B, measlesmumps-rubella, diphtheria-tetanus-pertussis, rabies, influenza, herpes zoster, yellow fever and COVID-19 4, 5, 6, 7, 8 . Other causes of transverse myelitis (TM) include post-infection reactions, autoimmune attack, metabolic disturbances and toxins. TM can also be caused by COVID-19 infection 9, 10, 11 .

Here we wish to report an instance of TM associated with the Pfizer-BioNTech vaccine, and review other publically-reported cases associated with COVID-19 vaccines.

A 32 year old Caucasian woman was referred for evaluation of multiple sclerosis. She was in good health until January 16, 2021 when within two hours of receiving the Pfizer-BioNTech Covid-19 vaccine she experienced a numbing sensation on the left lip. Three days later, she noted initially numbness of her right foot, which travelled proximally to her waistline, then the left foot and peroneal area. In addition, she felt a "tired" sensation in her legs and slight urinary incontinence. An MRI scan of the brain performed on February 28th, 2021 showed multiple, small periventricular and subcortical white matter lesions with subtle involvement of the corpus callosum, as well as a small contrast-enhancing lesion within the right temporal lobe. When she was evaluated on March 16th, she had reduced sharp touch sensation in her lower extremities and trunk with a T6 sensory level. Her past medical history was significant for chronic lower back pain since her teens with intermittent paresthesias of the right foot and gastric sleeve surgery for obesity in September of 2019 with subsequent weight loss of 80 lbs. Spinal cord imaging performed on March 21st showed a number of hyperintense signal abnormalities, including the left dorsolateral cord at C-4, a well-defined area of increased signal at T7-T8 with mild expansion of the cord and an ill-defined plaque on the right dorsolateral cord at T-10. The lesions did not enhance with contrast. She was diagnosed with incomplete transverse myelitis secondary to multiple sclerosis. Five days of high dose, intravenous methylprednisolone resulted mild improvement. She was referred for anti-CD20 treatment for long term therapy for MS.

Previous instances of TM associated with COVID-19 vaccination were obtain from the FDA's Vaccine Adverse Event Reporting System (VAERS) 12 (see Table 1 ). Listed are 25 cases of transverse myelitis. Sixteen are associated with the Pfizer-BioNTech vaccine, eight with the Moderna vaccine and one with the J&J/J vaccine. In three instances, the TM was associated with previously diagnosed or newly diagnosed MS. In addition to these cases, there are reports of two cases of transverse myelitis related to the AZ vaccine: one subject diagnosed with idiopathic TM 14 days after the booster injection and another within 10 days of the first injection. The latter was judged to have pre-existing multiple sclerosis after the event 11, 13 . The first case report, of which we are aware, of multiple sclerosis being diagnosed after an episode of transverse myelitis with the Pfizer-BioNTech vaccine, was recently reported 14 .

This is an example of incomplete TM secondary to multiple sclerosis, most likely triggered by the Pfizer-BioNTech vaccine. Our patient meets the MacDonald Criteria for multiple sclerosis based on her one clinical episode, multiple lesions in the brain and spine meeting the requirement for dissemination in space and an enhancing lesion in the brain meeting the requirement for dissemination in time 15 . Given the probable presence of lesions in the brain and possibly the spinal cord pre-vaccination, our patient likely would have been diagnosed with radiographically isolated syndrome, a precursor to multiple sclerosis 16 . Given the temporal relationship between COVID-19 vaccination and the onset of neurological symptoms, we believe that the vaccine triggered our patient's relapse.

To date, more than 130 million persons in the US have received at least one dose of the COVID-19 vaccine. Clearly, complications such as myelitis are rare. However, it is important that community physicians who will first encounter such patients be alert to the signs and symptoms of post vaccination myelitis so that such patients can receive expedient diagnosis and treatment.

Declaration of interests X The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. 

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