COVID-19-associated myelitis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Musadiq Ali M.B.B.S.[2] Tayebah Chaudhry[3]

Synonyms and Keywords:

Overview

In the current pandemic state, COVID-19 should be considered as a differential diagnosis in a patient presenting with acute myelitis. Acute Transverse Myelitis is a neurological condition characterized by inflammation and injury of the spinal cord. In a confirmed or newly diagnosed patient of COVID-19, it is thought to be either a direct consequence of viral infection or a sequalae of autoimmune-mediated response. COVID-19-associated myelitis is diagnosed based on the hallmark symptoms of acute myelitis and confirmed with changes on spinal MRI, after ruling out other possible etiologies of myelitis. The symptoms show marked improvement after treatment with steroids and plasma exchange.

Historical Perspective

  • First case of acute myelitis as a COVID-19 complication was reported in February 2020 in Wuhan by Kang Zhao et al, in a 66 year old male patient. [1]
  • The second case was reported in Boston by Sarma et al in a 28 year old female patient who developed acute myelitis 7 days after symptoms of upper respiratory tract infection. [2]
  • As of now, only few case reports have been published in literature showing an association of COVID-19 with acute myelitis as a neurological complication.

Classification

  • There is no established system for the classification of COVID-19-associated myelitis.

Pathophysiology

Causes

Apart from COVID-19 other causes of viral myelitis include[7]:

Other causes of myelitis are:

Differentiating COVID-19-associated myelitis from other Diseases

  • For further information about the differential diagnosis, click here.
  • To view the differential diagnosis of COVID-19, click here.

Epidemiology and Demographics

  • As of now, the incidence of acute myelitis associated with Covid-19 infection in unknown. [8][9]
  • To view epidemiology and demographics for COVID-19, click here.

Risk Factors

  • There are no established risk factors for COVID-19-associated myelitis. However, since this condition is a direct consequence of infection by the novel coronavirus, risk factors for COVID-19 should be considered.
  • To view the risk factors of COVID-19, click here.

Screening

  • Screening for COVID-19-associated myelitis is not currently done.
  • To view screening for COVID-19, click here.

Natural History, Complications, and Prognosis

Natural History

  • Myelitis associated with COVID-19 is an acute condition. The first case of COVID-19 associated myelitis developed the symptoms 5 days after the onset of fever. [1]
  • The second case developed symptoms of myelitis 7 days after the upper respiratory symptoms. [2]

Complications

  • Lack of prompt recognition and management may result in lasting neurological complications (such as residual loss of sensation in lower extremities) after novel corona virus infection. [2]

Prognosis

  • Exact prognosis of COVID-19-associated myelitis is not known.
  • Marked improvement in symptoms is seen with steroids and plasma exchange.

Diagnosis

Diagnostic Study of Choice

  • Diagnosis of COVID-19-associated myelitis is based on the hallmark symptoms of acute myelitis in a known case of COVID-19 or a positive PCR nasal swab for COVID-19 in a new patient. And classic contrast-enhancing lesions on MRI spine.
  • Hallmark symptoms of acute myelitis include bilateral symmetric weakness and sensory changes in extremities, urinary retention and lower back pain.
  • Absence of visual symptoms such as eye pain or vision loss ( classically seen in Multiple Sclerosis or Neuromyelitis optica), negative immunoglobulin G auto-antibodies or oligoclonal bands, negative anti-nuclear antibody (ANA) test (very sensitive test for autoimmune diseases such as lupus), absence of other system involvement (such as skin rash, nodules, cardiac arrhythmias or arthritis seen in lupus or sarcoidosis) rule out other possible etiologies. [8]

History and Symptoms

Common symptoms

Less common symptoms

  • Paresthesias in lower extremities with possible ascension to upper extremities [2]
  • Numbness in lower extremities with possible ascension to upper extremities[2]
  • Numbness in tip of tongue [2]

Physical Examination

Vitals:

Abnormal vitals can be seen due to COVID-19 association. These include:

Abdominal exam:

Neurological exam:

Neurological findings are symmetric and more severe in lower extremities. [1] [2] [8]

Laboratory Findings

Nasal swab:

Other Viral Screening:

MRI spine:

  • MRI findings consistent with Acute Transverse Myelitis (involving more than three spinal cord segments) are seen. This includes widespread elongated signal changes throughout the gray matter of spinal cord, with no disc pathology or spinal canal narrowing. [2]

Urinary retention:

Lumbar Puncture (LP):

To view the laboratory findings on COVID-19, click here

Electrocardiogram

  • There are no ECG findings associated with COVID-19-associated myelitis.
  • To view the electrocardiogram findings on COVID-19, click here.

X-ray

  • Chest X-ray may or may not show opacities in lungs depending on the degree of lung damage caused by COVID-19.
  • To view the x-ray finidings on COVID-19, click here.

Echocardiography or Ultrasound

CT scan

  • CT scan exclude other causes that can cause myelitis.
  • To view the CT scan findings on COVID-19, click here.

MRI

Treatment

Medical Therapy

  • Oxygen inhalation treatment with high-flow nasal catheters.
  • Ganciclovir ( 0.5g once daily) for 14 days, Lopinavir/ritonavir (500mg twice daily) for 5 days. "Coronavirus Disease 2019 (COVID-19) Treatment Guidelines".
  • Moxifloxacin (400mg once daily) for 6 days.(Treatment with arbidol and moxifloxacin could be helpful in reducing viral load and inflammation during SARS-CoV2 infection, especially for negatively regulating fatal inflammation in severe COVID-19 patients)[12].
  • Glutathione (1.8g once daily) for 14 days. (Glutathione inhibits replication of various viruses at different stages of the viral life cycle and decreasing viral load. It also prevents the massive release of inflammatory cells into the lungcytokine storm”)[13].
  • Dexamethasone (10mg once daily) for 10 days[14]. (NIH COVID-19 Treatment Guidelines Panel recommends using dexamethasone (at a dose of 6 mg per day for up to 10 days) in patients with COVID-19 who are mechanically ventilated and in patients with COVID-19 who require supplemental oxygen but who are not mechanically ventilated. And recommends against using dexamethasone in patients with COVID-19 who do not require supplemental oxygen.
  • Human immunoglobulin (15g once daily) for 7 days.
  • Pantoprazole (80mg once daily) for 10 days.
  • Mecobalamin (1000ug once daily) for 14days.[15] (Vitamin B12 may inhibit RNA-dependent-RNA polymerase activity of nsp12 protein from the COVID-19 Virus).
  • Plasma exchange.
  • Foley's catheter to relieve urinary retention

Surgery

  • Surgical intervention is not recommended for the management of COVID-19-associated myelitis.

Primary Prevention

Secondary Prevention

References

  1. 1.0 1.1 1.2 "www.medrxiv.org" (PDF).
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 "A Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection".
  3. Manji H, Carr AS, Brownlee WJ, Lunn MP (2020). "Neurology in the time of COVID-19". J Neurol Neurosurg Psychiatry. 91 (6): 568–570. doi:10.1136/jnnp-2020-323414. PMID 32312872 Check |pmid= value (help).
  4. Wan Y, Shang J, Graham R, Baric RS, Li F (2020). "Receptor Recognition by the Novel Coronavirus from Wuhan: an Analysis Based on Decade-Long Structural Studies of SARS Coronavirus". J Virol. 94 (7). doi:10.1128/JVI.00127-20. PMC 7081895 Check |pmc= value (help). PMID 31996437.
  5. Baig AM (2020). "Neurological manifestations in COVID-19 caused by SARS-CoV-2". CNS Neurosci Ther. 26 (5): 499–501. doi:10.1111/cns.13372. PMC 7163592 Check |pmc= value (help). PMID 32266761 Check |pmid= value (help).
  6. Pastor Bandeira, Isabelle; Machado Schlindwein, Marco Antônio; Breis, Leticia Caroline; Schatzmann Peron, Jean Pierre; Magno Gonçalves, Marcus Vinicius (2020). doi:10.20944/preprints202004.0304.v1. Missing or empty |title= (help)
  7. Pekcevik Y, Mitchell CH, Mealy MA, Orman G, Lee IH, Newsome SD; et al. (2016). "Differentiating neuromyelitis optica from other causes of longitudinally extensive transverse myelitis on spinal magnetic resonance imaging". Mult Scler. 22 (3): 302–11. doi:10.1177/1352458515591069. PMC 4797654. PMID 26209588.
  8. 8.0 8.1 8.2 8.3 8.4 8.5 AlKetbi, Reem; AlNuaimi, Dana; AlMulla, Muna; AlTalai, Nouf; Samir, Mohammed; Kumar, Navin (2020). "Acute Myelitis as a Neurological Complication ofCovid-19:A Case Report and MRI Findings". Radiology Case Reports. doi:10.1016/j.radcr.2020.06.001. ISSN 1930-0433.
  9. Munz M, Wessendorf S, Koretsis G, Tewald F, Baegi R, Krämer S; et al. (2020). "Acute transverse myelitis after COVID-19 pneumonia". J Neurol. doi:10.1007/s00415-020-09934-w. PMC 7250275 Check |pmc= value (help). PMID 32458198 Check |pmid= value (help).
  10. "Acute transverse myelitis after COVID-19 pneumonia".
  11. Scotti G, Gerevini S (2001). "Diagnosis and differential diagnosis of acute transverse myelopathy. The role of neuroradiological investigations and review of the literature". Neurol Sci. 22 Suppl 2: S69–73. doi:10.1007/s100720100038. PMID 11794482.
  12. Yu, Dongshan; Sun, Shuilin; Li, Yanhua; Xi, Wenna; Jin, Di; Sun, Ke; Yu, Rongyan; Yao, Xuebing; Song, Zhiying; Yang, Aoyu; Luo, Ruixia; Zou, Biaoshu; Liu, Yun (2020). doi:10.1101/2020.05.30.20117598. Missing or empty |title= (help)
  13. De Flora, S.; Grassi, C.; Carati, L. (1997). "Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment". European Respiratory Journal. 10 (7): 1535–1541. doi:10.1183/09031936.97.10071535. ISSN 0000-0000.
  14. Sotoca, Javier; Rodríguez-Álvarez, Yensa (2020). "COVID-19-associated acute necrotizing myelitis". Neurology - Neuroimmunology Neuroinflammation. 7 (5): e803. doi:10.1212/NXI.0000000000000803. ISSN 2332-7812.
  15. nair, deepak t; narayanan, naveen. doi:10.35543/osf.io/p48fa. Missing or empty |title= (help)