key: cord-0981072-fldv89l1 authors: Valiuddin, Hisham; Skwirsk, Brandon; Paz-Arabo, Patricia title: Acute Transverse Myelitis Associated with SARS-CoV-2: A Case-Report date: 2020-06-06 journal: Brain Behav Immun Health DOI: 10.1016/j.bbih.2020.100091 sha: 16d4894fae6248fe3cc12df60e6fa746aaaf7890 doc_id: 981072 cord_uid: fldv89l1 • The third case of acute transverse myelitis due to SARS-CoV-2 reported in the world; • Possible inflammatory complications affecting the myelin in spinal cord. • We must be vigilant of the critical neurological illnesses associated with COVID-19. We describe the third reported case of transverse myelitis in a patient with the onset of coronavirus disease 2019 (Covid-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although it is a well-known fact now that strains of SARS-CoV-2 can cause neurological manifestations such as anosmia and dysgeusia, recent literature has found complex neurological disease associations such as Guillain-Barré syndrome and early-onset large-vessel strokes [1] [2] [3] . It has become apparent that Covid-19 causes an inflammatory cascade that results in multiple organ system being affected. In this case, inflammatory complications affecting the myelin in spinal cord occurred without the classic Covid-19 symptoms. On April 3, 2020, a 61-year-old female presented with a chief complaint of generalized weakness. She stated that her symptoms initially started with rhinorrhea and chills a week ago. She was suspicious that she had coronavirus because she had been exposed to several symptomatic coworkers potentially with Covid-19, so she was constantly checking her temperature; however, she was afebrile throughout. Three days afterward, she started also developing numbness and tingling in her hands and feet. Over the next 48 hours, this progressed to severe weakness in her lower extremities bilaterally. She began having difficulty with ambulation and standing, further stating that the numbness had ascended to the level of her abdomen and with associated symptoms of constipation and difficulty voiding. Table 1 . Electromyography findings were consistent with a distal and motor, axonal-loss predominant, polyneuropathy impacting the lower extremities with evidence of ongoing active denervation. There was sparing of all sensory nerves tested. No evidence of demyelination was found. Unfortunately, the patient is still undergoing inpatient physical rehabilitation, requiring an intensive degree of interdisciplinary therapies. She is suffering paraplegia, neurogenic bladder, and subsequent impairments in mobility and the ability to complete activities of daily living. However, she has significant improvement in her sensation and fewer muscle spasms are appreciated. She continues to receive three hours of therapy daily, five days per week. Inflammation of the spinal cord, otherwise known as transverse myelitis, has been well documented as a result of viral infections, bacterial infections, and immune system disorders [4]. There is no cure for transverse myelitis. Typical treatments are only aimed at preventing or minimizing permanent neurological deficits. These treatments include corticosteroid and other therapies that suppress the immune system, such as plasmapheresis if there is poor response to initial treatment. Most patients partially recover within three months to two years after initial diagnosis. Some degree of disability may remain, but physical therapy has been shown to improve outcomes. Scattered reports since the 1980s have suggested certain coronavirus genotypes, which include SARS-CoV in 2003, have neurotropic properties, and sometimes neurologically devastating results such as encephalomyelitis, Guillain-Barre, seizure, and loss of neurofunctional status [5] . The first case of SARS-CoV-2 causing acute myelitis was published in March 2020 from a center in Wuhan, China where the outbreak first began, and the second case being reported April 2020 from Harvard [6] [7] . Some ways by which our case differs is that our patient was afebrile throughout her presentation and course, never developed flaccid paralysis or respiratory distress, and symptoms progressed to urinary/fecal incontinence. This is important to highlight the atypical presentations of Covid-19. It is also worth noting that the first case and the recently reported cases of Guillain-Barré syndrome due to SARS-CoV-2, have all had negative polymerase-chain-reaction assay of the CSF for SARS-CoV-2 [3] . Although the CSF studies in this patient indicated a pathology such as atypical Guillain-Barré syndrome, the MRI studies revealed the true pathological process at hand (Figure 1 ). One proposed mechanism for the neurologic disease has been the presence of ACE2 receptors that are expressed on the membrane of spinal cord neurons [6] . There is a need for more evidence to understand the pathogenesis and subsequent neurological sequelae of active or recent infections with SARS-CoV-2. This case demonstrates the importance of keeping a broad differential at a time when the body of evidence regarding Covid-19 continues to grow. While we learn more about the pandemic caused by SARS-CoV-2, we must be vigilant of the critical neurological illnesses that could be affecting our patients. Smell And Taste Dysfunction In Patients With Large-Vessel Stroke As A Presenting Feature Of Covid-19 In The Young | NEJM Guillain-Barré Syndrome Associated With SARS-Cov-2 | NEJM Transverse Myelitis Fact Sheet | National Institute Of Neurological Disorders And Stroke Neurologic Alterations Due To Respiratory Virus Infections Acute Myelitis After SARS-Cov-2 Infection: A Case Report A Case Report Of Acute Transverse Myelitis Following Novel Coronavirus Infection • The third case of acute transverse myelitis due to SARS-CoV-2 reported in the world • Possible inflammatory complications affecting the myelin in spinal cord We must be vigilant of the critical neurological illnesses associated with COVID-19 Office.