Doukas Sotirios G, Santos Andrea P, Mir Waleed, Daud Sarosh, Zivin-Tutela Tracy H
Department of Forensic Sciences and Laboratory of Toxicology, University of Crete, School of Medicine, Heraklion, GRC.
Department of Medicine, Saint Peter's University Hospital, New Brunswick, USA.
Cureus. 2022 Apr 6;14(4):e23877. doi: 10.7759/cureus.23877. eCollection 2022 Apr.
The coronavirus disease 2019 (COVID-19) includes an extensive spectrum of clinical manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Previous studies have shown that SARS-CoV-2 often exhibits central nervous system (CNS) manifestations, including encephalitis, meningitis, and spinal cord pathologies. To date, few cases of COVID-19-associated transverse myelitis (TM) have been described. A 40-year-old unvaccinated man with no significant medical history presented to the emergency department complaining of fever, worsening burning sensation in his lower extremities, unsteady gait, and difficulty initiating urination for five days. Twelve days before presentation, the patient had tested positive for SARS-CoV-2 infection. Physical examination revealed hyperesthesia, starting around the nipple line (T4) and extending distally, involving the lower extremities, accompanied by symmetric weakness in the lower extremities. Magnetic resonance imaging of the thoracic spine with and without contrast revealed mild intramedullary signal abnormality at T3-T4 and T6-T8, confirming the suspicion of TM. Further laboratory testing revealed a C-reactive protein level of 67 mg/L, lactate dehydrogenase level of 181 mg/L, serum B12 level of 781 pg/mL, methylmalonic acid level of 165 nmol/L, folate of >24.5 ng/mL, and thyroid-stimulating hormone level of 0.481 μIU/L. Lumbar puncture was performed, and cerebrospinal fluid analysis revealed a cell count of 14 cells/µL, with 69% lymphocytes, glucose level of 81 mg/dL, protein level of 32 mg/dL, and negative cultures. Human immunodeficiency virus, antinuclear antibody screening, anti-DNA, rapid plasma reagin, Lyme serology, anti-SSA, and anti-SSB antibodies were unremarkable. Serum aquaporin-4 immunoglobulin G was negative, and myelin oligodendrocyte glycoprotein (MOG) antibodies were positive. The patient was treated with intravenous methylprednisolone and oral gabapentin and was discharged after five days when his urinary retention improved. Most previously reported cases of COVID-19-related TM were negative for autoimmune workup. Although the exact pathophysiology of COVID-19-related TM remains unclear, one hypothesis suggests that it is a consequence of the direct viral invasion. However, our patient had MOG antibodies, suggesting the possible involvement of a different mechanism. In MOG-associated TM, it has been suggested that MOG antibodies gain access to the CNS through disruption of the blood-brain barrier. This unique presentation demonstrates that further studies are needed to understand the effects of SARS-CoV-2 infection on the immune and nervous systems. It also highlights that young and otherwise healthy patients are at risk of severe COVID-19-related complications, including CNS disorders.
2019年冠状病毒病（COVID-19）包括严重急性呼吸综合征冠状病毒2（SARS-CoV-2）感染的广泛临床表现谱。既往研究表明，SARS-CoV-2常表现出中枢神经系统（CNS）表现，包括脑炎、脑膜炎和脊髓病变。迄今为止，COVID-19相关横贯性脊髓炎（TM）的病例报道较少。一名40岁未接种疫苗且无重大病史的男性因发热、下肢烧灼感加重、步态不稳及排尿困难5天就诊于急诊科。就诊前12天，该患者SARS-CoV-2感染检测呈阳性。体格检查发现感觉过敏，起自乳头线（T4）周围并向远端延伸，累及双下肢，同时伴有双下肢对称性无力。胸椎磁共振成像（平扫及增强）显示T3-T4和T6-T8节段脊髓内轻度信号异常，证实了TM的诊断。进一步实验室检查显示，C反应蛋白水平为67mg/L，乳酸脱氢酶水平为181mg/L，血清维生素B12水平为781pg/mL，甲基丙二酸水平为165nmol/L，叶酸>24.5ng/mL，促甲状腺激素水平为0.481μIU/L。行腰椎穿刺，脑脊液分析显示细胞计数为14个/μL，淋巴细胞占69%，葡萄糖水平为81mg/dL，蛋白水平为32mg/dL，培养结果为阴性。人类免疫缺陷病毒、抗核抗体筛查、抗DNA、快速血浆反应素、莱姆病血清学、抗SSA和抗SSB抗体均无异常。血清水通道蛋白4免疫球蛋白G阴性，髓鞘少突胶质细胞糖蛋白（MOG）抗体阳性。患者接受静脉注射甲泼尼龙和口服加巴喷丁治疗，5天后因尿潴留改善而出院。大多数先前报道的COVID-19相关TM病例自身免疫检查为阴性。尽管COVID- related TM的确切病理生理学尚不清楚，但一种假说认为它是病毒直接侵袭的结果。然而，我们的患者存在MOG抗体，提示可能涉及不同机制。在MOG相关TM中，有人提出MOG抗体通过血脑屏障破坏进入中枢神经系统。这种独特的表现表明，需要进一步研究以了解SARS-CoV-2感染对免疫和神经系统 的影响。它还强调了年轻且其他方面健康的患者有发生严重COVID-19相关并发症（包括中枢神经系统疾病）的风险。
