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Letter to the Editor
Acute transverse myelitis following SARS-CoV-2 infection
Mielitis transversa aguda asociada a infección por SARS-CoV-2
C. Jauregui-Larrañaga
Corresponding author
carlota_l13@hotmail.com

Corresponding author.
, A. Ostolaza-Ibáñez, M. Martín-Bujanda
Servicio de Neurología, Complejo Hospitalario de Navarra (CHN), Navarra, Spain
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he consulted due to dysaesthesia in the lower limbs and inability to walk independently&#46; He presented no respiratory symptoms or lung involvement at any time&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Neurological examination revealed preserved motor strength&#44; vibratory and tacto-algesic hypoaesthesia at the T9-T10 sensory level&#44; exaggerated deep tendon reflexes in the lower limbs&#44; bilateral Babinski sign&#44; ataxic gait&#44; and urinary retention&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Head and lumbar spine CT studies revealed no abnormal findings&#46; A blood analysis detected mildly elevated levels of acute-phase reactants&#46; Autoimmune test results were normal&#46; Suspecting acute transverse myelitis&#44; we performed a CSF analysis&#44; which revealed pleocytosis with mononuclear cells and high protein levels&#44; with no glucose uptake&#46; A microbiological study of the CSF sample yielded negative results&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The neurological symptoms significantly worsened during hospitalisation&#44; with progression to severe paraparesis&#44; and a urinary catheter had to be placed&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">An MRI study &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41; revealed a slight signal alteration in the T6-T11 segments&#44; with hyperintensity on T2-weighted sequences&#59; the lesion did not present gadolinium uptake or mass effect&#46; These findings are compatible with longitudinally extensive transverse myelitis of the thoracic spinal cord&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">We administered a 5-day cycle of methylprednisolone dosed at 1000&#160;mg per day&#44; observing no improvement&#46; Due to the ineffectiveness of the treatment&#44; we administered intravenous immunoglobulins dosed at 0&#46;4&#160;g&#47;kg&#47;day for 5 days&#46; Progression was satisfactory&#44; and the patient was able to walk independently at discharge&#44; although impaired proprioception persisted&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The neurological manifestations of SARS-CoV-2 infection described to date are diverse&#44; and present in up to one-third of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The most frequent symptoms are headache&#44; dizziness&#44; altered level of consciousness&#44; and anosmia&#46; Isolated cases have been reported of seizures&#44; acute encephalitis&#44; stroke&#44; Guillain-Barr&#233; syndrome&#44; and transverse myelitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The diagnostic criteria for transverse myelitis include the presence of bilateral sensory&#44; motor&#44; and autonomic dysfunction at a defined sensory level&#44; progression to the maximal level of disability between 4&#160;hours and 21 days&#44; evidence of spinal cord inflammation due to pleocytosis&#44; elevated CSF IgG levels&#44; and gadolinium uptake on MRI&#44; with compressive&#44; neoplastic&#44; vascular&#44; and post-radiation causes having been ruled out&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> SARS-CoV-2 infection is diagnosed with PCR testing of a nasopharyngeal swab&#44; given the low sensitivity of PCR testing of CSF&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The treatment of choice for transverse myelitis is high-dose methylprednisolone&#59; if this is ineffective&#44; intravenous immunoglobulins should be considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">SARS-CoV-2 can affect the nervous system by direct invasion or through an exaggerated systemic inflammatory response to the virus&#46; The latter mechanism causes increased permeability of the blood-brain barrier and massive release of proinflammatory cytokines&#44; which in turn cause oedema and immune-mediated damage to the spinal cord&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> SARS-CoV-2 has been shown to invade human cells by binding to the angiotensin-converting enzyme 2 &#40;ACE2&#41; receptor&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;10</span></a> Microarray studies have demonstrated ACE2 expression in the cerebral cortex&#44; basal ganglia&#44; hypothalamus&#44; brainstem&#44; and brain capillary endothelium&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> This marked ACE2 receptor expression in the human brain may explain the neuroinvasive capacity of the virus&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> The virus may also spread through the central nervous system via the olfactory bulb&#59; studies of intranasal inoculation with SARS-CoV-2 in mice have shown that the virus is able to penetrate the brain&#44; brainstem&#44; and spinal cord&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Currently&#44; the mechanisms of SARS-CoV-2 virulence and the pathophysiology of COVID-19 are not fully understood&#46; Despite this&#44; it seems plausible that the abundant expression of ACE2 receptors in the brain parenchyma favours interaction with the virus&#44; increasing the risk of neurological complications&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0060" class="elsevierStylePara elsevierViewall">This study received no funding of any kind&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos