COVID-19-Associated Myelopathies: A Comprehensive Analysis with MRI Insights and Literature Review


In an unprecedented observation, four male patients aged between 37 to 72 years old were reported to have developed myelopathies associated with coronavirus disease 2019 (COVID-19), presenting a compelling case study on the neurological impacts of the virus beyond its more commonly known respiratory symptoms. These cases, emerging with latencies ranging from 5 to 80 days post-COVID-19 infection, underscore the virus’s potential to cause severe neurological complications, including myelitis, in infected individuals.

The initial symptoms reported by these patients were primarily numbness and weakness in the lower limbs, with one case also experiencing back pain alongside the weakness. As the conditions progressed, the patients exhibited peak symptoms that included paraplegia, sphincter dysfunction, sensory disturbance level, and spastic gait, with their Expanded Disability Status Scale (EDSS) scores ranging between 7.5 to 9.0, indicating severe disability.

Magnetic Resonance Imaging (MRI) played a crucial role in diagnosing these conditions, revealing delayed and atypical spinal cord lesions. Notably, at the onset, two cases showed no lesions, one presented with linear spinal meningeal enhancement, and the other with punctate lesions on T2-weighted imaging (T2WI). These findings evolved over time, with follow-up MRIs displaying a variety of lesions in the lateral and posterior funiculus, including punctate, linear, and cloudy appearances on T2WI during the peak stage of symptoms. The discordance between the clinical severity and the MRI findings, particularly the linear spinal meningeal enhancement and the inapparent lesions in early stages, highlighted the complexity of diagnosing COVID-19-associated myelopathy.

The long-term outcomes for these patients were grim, with all four experiencing significant disabilities. Two were left completely bedridden, and the other two were only able to stand with support, indicating the severe impact of COVID-19-associated myelopathies on individuals’ quality of life.

This phenomenon of neurological manifestations following COVID-19 infection, including myelitis, presents a severe clinical challenge. Transverse myelitis (TM) post-COVID-19 has been documented, with an incidence of 0.5 per million from a series in Italy, suggesting that myelitis might account for 1.2% of all neurological complications arising from COVID-19. Unlike traditional TM, COVID-19-associated myelitis can exhibit significant differences in clinical manifestations, progression, and MRI features, with some patients presenting delayed onset of symptoms up to three months after infection and others showing typical TM symptoms but with normal spinal MRI results. These scenarios complicate the diagnosis and timely treatment of the condition.

The pathophysiology behind COVID-19-associated myelopathy remains an area of active investigation. The virus may affect the nervous system both directly and indirectly, through mechanisms such as immune-mediated responses or hypercoagulable states, leading to diverse neurological symptoms. The diagnostic criteria for COVID-19-associated myelitis, as proposed by Ellul et al., categorize the condition into confirmed, probable, and possible cases based on the presence of COVID-19 infection and neurological manifestations that cannot be attributed to other causes.

MRI findings in COVID-19-associated myelitis are notably varied, ranging from classic T2 hyperintensities to more atypical features such as discontinuous, pointy, or patchy lesions. The diversity in MRI presentations, including linear meningeal enhancement and the development of lesions from the spinal meningeal to the spinal cord parenchyma, underscores the importance of MRI in diagnosing and understanding the progression of the disease.

The prognosis for patients with COVID-19-associated myelitis and atypical or absent initial MRI findings appears poor, with traditional treatments like corticosteroids and plasma exchange showing limited efficacy. The connection between normal early MRI scans and poor outcomes suggests the need for alternative diagnostic and therapeutic approaches.

In summary, the reporting of these four cases of COVID-19-associated myelitis with delayed and atypical MRI characteristics highlights the critical need for awareness and recognition of neurological complications associated with COVID-19. The findings stress the importance of considering COVID-19 in the differential diagnosis of myelopathy, particularly in patients with delayed and atypical spinal cord findings on MRI, to ensure prompt and appropriate clinical management. Further research into the mechanisms underlying these atypical MRI findings and the development of effective treatments is imperative to improve outcomes for patients affected by this severe complication of COVID-19.

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