The patient is a 65-year-old male. He developed a fever on December 25, 2022, with a temperature of 38.2°C, accompanied by cough, expectoration, and general fatigue. He tested positive for COVID-19 antigen. After self-administering Phenamine for two days, his fever subsided. On the third day, he experienced chest tightness and discomfort below the mid-abdomen. He was admitted to our hospital through the emergency department on January 2, 2023. The day after admission, which was January 2, 2023, the patient began to experience a gradual decrease in muscle strength in both lower limbs, which progressively worsened. The level lesion gradually ascended, and within five days, the muscle strength decreased to Grade 1, rendering the patient unable to get out of bed and walk, and he also developed urinary retention. Three days later, the muscle strength in both upper limbs also began to decline, progressively decreasing to Grade 3, leaving the patient unable to hold a cellphone. The numbness and the feeling of constriction also rose to the level around the umbilicus. Five days later, Babinski's sign turned positive. The patient's condition progressed, and he was moved to the intensive care unit for advanced care and monitoring.
On January 6, 2023, an MRI of the lumbar spine was performed: Degeneration and protrusion of the intervertebral discs at L1-2, L2-3, and L5-S1 were observed, with no lesions seen in the spinal cord. On January 9, 2023, an MRI of the cervical spine with and without contrast was conducted: Dispersed abnormal signals were found in the medulla oblongata and the cervical-thoracic segment of the spinal cord, presenting as slightly low signals on T1-weighted images and slightly high signals on T2-weighted images, with significant enhancement after contrast. Considerations include: (1) demyelinating lesions; (2) inflammatory lesions (see Fig. 1a). Lumbar puncture was also performed on January 9, 2023. Cerebrospinal fluid (CSF) analysis: clear appearance; Pandy's test: negative; red blood cells 0–2, white blood cells 15×10^6, with 14% neutrophils and 86% lymphocytes. CSF biochemistry: chloride 125 mmol/L, protein 300 mg/L, glucose 4.4 mmol/L. CSF neuroimmunological testing revealed: (1) CSF albumin and IgA levels within normal reference ranges, elevated IgG and IgM levels. QA1b value slightly increased, suggesting a possibility of minor blood-brain barrier impairment; (2) normal CSF IgG synthesis index; (3) according to Reiber's coordinate analysis, IgG, IgA, IgM were at the border between normal reference range and the zone indicative of pure blood-brain barrier dysfunction (intersection of Zone 1 and 2); (4) isoelectric focusing immunofixation electrophoresis analysis showed no oligoclonal bands (OB bands) in GSF and Serum; (5) normal 24-hour CSF IgG intrathecal synthesis rate. Based on the patient's clinical presentation and laboratory tests, the diagnoses are: (1) COVID-19; (2) COVID-19-associated ATM (acute transverse myelitis).
Beginning January 10, 2023, high-dose glucocorticoid pulse therapy was initiated: intravenous administration of methylprednisolone 500 mg once daily for 3 days, followed by 240 mg once daily for 3 days, 120 mg once daily for 3 days, and 80 mg once daily for 3 days. Subsequently, the patient was shifted to oral prednisone 60 mg once daily for 2 weeks, with a reduction of 5 mg every 2 weeks.
Four days after the treatment, there was slight improvement in the muscle strength of the limbs. Twelve days after the treatment, the muscle strength in the limbs gradually recovered to Grade 5, and the patient was able to get out of bed and walk slowly with the help of a walker. The sensation of constriction from the mid-abdomen to the lower limbs improved compared to before, but urinary retention persisted.
To further improve symptoms, on January 17, 2023, the patient was administered intravenous immunoglobulin at a dosage of 0.4 g/d/kg for a total of 10 days. On January 30, 2023, a follow-up MRI of the cervical spine with and without contrast was performed: Dispersed patchy abnormal signals were observed in the spinal cord at the cervical and thoracic 3 levels, presenting as high signals on T2WI with unclear boundaries, and showing patchy enhancement after contrast. This was considered to be an inflammatory lesion, and compared to the images from January 9, 2023, some lesions had been absorbed (see Fig. 1b). Subsequently, the patient's motor function improved compared to before, he was able to perform daily activities independently, and there was significant improvement in urinary retention. The patient was discharged with the urinary catheter removed.
On March 1, 2023, the patient came for an outpatient follow-up, and an electromyography (EMG) test was conducted on the same day: (1) Sensory potentials of the left and right sural nerves were not elicited; (2) No denervation changes were observed in the muscles of the limbs; (3) Somatosensory evoked potentials (SEPs) of both upper and lower limbs were within the normal range. During the outpatient follow-up on April 13, 2023, an MRI of the cervical spine was performed, showing: Scattered patchy abnormal signals in the cervical spinal cord, presenting as high signals on T2WI with unclear boundaries, suggestive of inflammatory lesions, which showed slight improvement compared to the previous MRI (2023-1-30) (see Fig. 1c). On another outpatient follow-up on June 27, 2023, an MRI of the cervical and thoracic spine with and without contrast was conducted, indicating: Uneven signals in the cervical spinal cord with dispersed small patchy hypointense T2WI high signal shadows, no significant enhancement after contrast, and compared to the previous MRI (2023-4-13), there was a significant reduction in abnormal signals in the cervical cord, suggesting alleviation of myelitis; the thoracic cord signal was normal, with no abnormal enhancement after contrast, and compared to the previous MRI (2023-4-13), the abnormal signal in the thoracic spinal cord disappeared, indicating significant alleviation of myelitis (see Fig. 1d).