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IntroductionAlthough acute transverse myelitis (ATM) is a rare neurological condition (1.34-4.6 cases per million/year) COVID-19-associated ATM cases have occurred during the pandemic.Case-finding methodsWe report a patient from Panama with SARS-CoV-2 infection complicated by ATM and present a comprehensive clinical review of 43 patients with COVID-19-associated ATM from 21 countries published from March 2020 to January 2021. In addition, 3 cases of ATM were reported as serious adverse events during the clinical trials of the COVID-19 vaccine ChAdOx1 nCoV-19 (AZD1222).ResultsAll patients had typical features of ATM with acute onset of paralysis, sensory level and sphincter deficits due to spinal cord lesions demonstrated by imaging. There were 23 males (53%) and 20 females (47%) ranging from ages 21- to 73- years-old (mean age, 49 years), with two peaks at 29 and 58 years, excluding 3 pediatric cases. The main clinical manifestations were quadriplegia (58%) and paraplegia (42%). MRI reports were available in 40 patients; localized ATM lesions affected ≤3 cord segments (12 cases, 30%) at cervical (5 cases) and thoracic cord levels (7 cases); 28 cases (70%) had longitudinally-extensive ATM (LEATM) involving ≥4 spinal cord segments (cervicothoracic in 18 cases and thoracolumbar-sacral in 10 patients). Acute disseminated encephalomyelitis (ADEM) occurred in 8 patients, mainly women (67%) ranging from 27- to 64-years-old. Three ATM patients also had blindness from myeloneuritis optica (MNO) and two more also had acute motor axonal neuropathy (AMAN).ConclusionsWe found ATM to be an unexpectedly frequent neurological complication of COVID-19. Most cases (68%) had a latency of 10 days to 6 weeks that may indicate post-infectious neurological complications mediated by the host’s response to the virus. In 32% a brief latency (15 hours to 5 days) suggested a direct neurotropic effect of SARS-CoV-2. The occurrence of 3 reported ATM adverse effects among 11,636 participants in the AZD1222 vaccine trials is extremely high considering a worldwide incidence of 0.5/million COVID-19-associated ATM cases found in this report. The pathogenesis of ATM remains unknown, but it is conceivable that SARS-CoV-2 antigens –perhaps also present in the AZD1222 COVID-19 vaccine or its chimpanzee adenovirus adjuvant– may induce immune mechanisms leading to the myelitis.

Background: Acute transverse myelitis (ATM) is a rare neurological complication of viral infections and vaccinations. We report a 72-year-old man with SARS-CoV-2-associated cervicothoracic ATM in Panama, and analyze the results of a bibliographic investigation on myelitis during COVID-19. Methods: Systematic review of 38 patients with COVID-19-associated myelitis from 19 countries published between March and October 2020. Findings: All patients had typical features of ATM with acute onset of paralysis, sensory level, and sphincter deficits due to spinal cord lesions demonstrated by imaging. There were 21 men (55%) and 17 women (age range, 21-73 years; mean age, 49 years) with two age peaks at 29 and 58 years, excluding two pediatric cases. Longitudinally-extensive ATM involved cervicothoracic segments in 14 cases (42%), localized ATM lesions affected cervical (10 cases) and thoracic cord segments (7 cases). Acute disseminated encephalomyelitis (ADEM) occurred in 7 patients, mainly women (67%) with ages ranging from 27 to 64 years. Two patients had blindness due to myeloneuritis optica, and 2 had acute motor axonal neuropathy. Interpretation: Acute myelitis is an unexpectedly frequent neurological complication of COVID-19. Short latency from onset of infection to first neurological symptoms may indicate a direct neurotropic effect of SARS-CoV-2 during the initial infection, while longer latency of the post-infectious neurological complications may be mediated by the host’s response to the virus. The immune mechanisms causing ATM remain unknown. It is conceivable that common antigens inducing ATM may occur in both SARS-CoV-2 and in the ChAdOx1 nCoV-19 Chimpanzee adenovirus vaccine. (ClinicalTrials.gov Identifier: NCT04324606). Funding: None. Declaration of Interests: The authors declare no competing interests.