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  IN THIS Article
 ::  Abstract
  ::  Introduction
  ::  Case Report
  ::  Investigations
  ::  Discussion
  ::  Conclusion
 ::  References
 ::  Article Figures

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  Table of Contents     
CASE REPORT
Year : 2022  |  Volume : 68  |  Issue : 3  |  Page : 179-181

Longitudinally extensive transverse myelitis following ChAdOx1 nCoV-19 vaccine


Department of Endocrinology and Metabolism, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission06-Nov-2021
Date of Decision03-Mar-2022
Date of Acceptance13-Apr-2022
Date of Web Publication16-Aug-2022

Correspondence Address:
A Rastogi
Department of Endocrinology and Metabolism, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpgm.jpgm_1047_21

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 :: Abstract 


Transverse myelitis (TM) has been reported in association with various vaccinations. Herein we describe a case of longitudinally extensive transverse myelitis (LETM) associated with vaccination with ChAdOx1 nCoV-19 (COVISHIELD) vaccine. A 59-year-old woman with no prior co-morbidities presented with lower extremity numbness, weakness, acute urinary retention, and constipation. Numbness gradually extended up to the lower costal margin with band like sensation. She had received the vaccine 5 days prior to the onset of the symptoms. Extensive diagnostic evaluation effectively ruled out causes other than vaccination-associated transverse myelitis. Following treatment with intravenous methylprednisolone, the patient made a significant recovery. TM may be associated with vaccination against the novel ChAdOx1 nCoV-19 vaccine and we believe this to be the first report from India of LETM associated with this vaccine.


Keywords: Adverse event, corticosteroids, COVID-19 vaccine, SARS-CoV-2, transverse myelitis


How to cite this article:
Shetty A J, Rastogi A, Jha V, Sudhayakumar A. Longitudinally extensive transverse myelitis following ChAdOx1 nCoV-19 vaccine. J Postgrad Med 2022;68:179-81

How to cite this URL:
Shetty A J, Rastogi A, Jha V, Sudhayakumar A. Longitudinally extensive transverse myelitis following ChAdOx1 nCoV-19 vaccine. J Postgrad Med [serial online] 2022 [cited 2022 Oct 4];68:179-81. Available from: https://www.jpgmonline.com/text.asp?2022/68/3/179/353842





 :: Introduction Top


Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) has claimed countless lives all over the world, but 2020 also has seen 58 vaccines against SARS-CoV-2 being developed including some in clinical trials. Widespread vaccination against novel COVID 19 has been implemented globally for breaking the chain of transmission. Although vaccination has been associated with autoimmune sequelae, relatively few of these complications have been reported in association with the vaccine to date, despite its extensive use.[1] Herein, we report a rare case of longitudinally extensive (LE) transverse myelitis (TM), that occurred shortly after vaccination with the COVISHIELD vaccine.


 :: Case Report Top


A 59-year-old female presented with acute urinary retention with intact bladder sensation and constipation for 15 days, followed by numbness and gradually progressive weakness involving bilateral lower limbs for 10 days. Numbness of the legs gradually extended up to the costal margin and was associated with band like sensation. She reported no prior neurological symptoms, respiratory, gastrointestinal illness, or fever preceding the onset of symptoms. She had received the first dose of ChAdOxx1 nCoV-19 (recombinant, replication-deficient chimpanzee adenovirus vector encoding the SARS-CoV-2 Spike (S) glycoprotein, COVISHIELD) vaccine intramuscular 5 days prior to the onset of symptoms. There was no prior history of testing positive for COVID or history of any other vaccinations including hepatitis B in the past 1 year.

On neurological examination, she had paraplegia (Medical Research Council Muscle Scale 3/5) involving proximal and distal muscle groups with hypotonia and diffuse hyperreflexia but normal power and tone in the upper limbs. Plantar response was extensor. Abdominal reflexes were absent. All modalities of sensations were diminished below the sixth thoracic segmental level. Higher mental functions and cranial nerve examination revealed no abnormality. A provisional diagnosis of transverse myelitis and neuromyelitis optica was considered. Other differentials that were considered were multiple sclerosis and vasculitis with multi-system involvement.


 :: Investigations Top


On the day of admission, haemogram, renal, liver, and thyroid function tests were within normal limits. Viral serology for hepatitis B, hepatitis C, and Human immunodeficiency virus I and II were negative. Her chest X-ray was normal. Antinuclear antibodies, Anti-neutrophil cytoplasmic antibodies, aquaporin-4 antibodies & Anti myelin oligodendrocyte glycoproteins antibodies were undetectable. Nasopharyngeal swab for Reverse Transcription-polymerase chain reaction test to detect SARS-CoV-2 was negative on admission. Lumbar puncture was performed for cerebrospinal fluid (CSF) study which revealed lymphocytic pleocytosis with 207 cells (98% lymphocytes) and elevated protein levels (71 mg/dL); gram stain was negative. CSF evaluation for tuberculosis was negative. Contrast-Enhanced Magnetic Resonance Imaging of the brain was normal. On Day-2 of admission, T2-weighted MRI imaging of the dorsal spine revealed hyperintensity in the spinal cord involving the cervical cord and lower thoracolumbar cord (D7 – L1), suggestive of longitudinally extensive transverse myelitis (LETM) [Figure 1]. Subsequent nerve conduction studies of sural, median, and ulnar nerves (D-3 of admission) were normal. A diagnosis of LETM was corroborated secondary to vaccination considering the temporal correlation with ChAdOxx1 nCoV-19 vaccine.
Figure 1: T2 weighted magnetic resonance images demonstrating longitudinally extensive transverse myelitis. Cervical I (a), sagittal thoracic I (b), and cross-section thoracic I (c) spinal cord views are shown

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Treatment

Daily intravenous methylprednisolone at a dose of 1 g/day (pulse therapy) was started following a lumbar puncture on the day of admission with a clinical diagnosis (provisional) of transverse myelitis. MRI done on the second day of admission was consistent with the diagnosis of myelitis and steroid was continued. After three doses of pulse steroid, subjective improvement in the power of the lower limb in the form of raising her legs against resistance was noticed. The patient was able to feel all forms of sensations up to the medial aspect of the bilateral ankle. After five days of pulse therapy (D-6), she was switched over to oral prednisolone (1 mg/kg). Her symptoms significantly improved (end of first week) with steroids and she was able to walk with no difficulty, able to void, and pass stool on her own. She was discharged after one week of admission and followed weekly (telephonically), that confirmed remission. Subsequently, steroids were tapered off over 6 weeks.


 :: Discussion Top


Herein, we describe the first case of LETM as a serious adverse event (SAE) following COVID vaccination from India. Though some cases of transverse myelitis have been described in the past following hepatitis B virus, measles-mumps-rubella, diphtheria-tetanus-pertussis, and others, it is still not a common complication following vaccination.[2],[3] A systemic review identified only 37 cases of transverse myelitis following vaccination other than COVID.[4] Transverse myelitis as an adverse event to COVID vaccine was first identified during Astra Zeneca's COVID-19 vaccine trial as an association with vaccine.[5] However, the causal relationship of vaccination with TM has not yet been well established. The concept of molecular mimicry has been postulated whereby in genetically predisposed individuals the offending agent triggers an autoimmune response to the myelin sheath of the central tracts of the spinal cord.[6] Similarly, the suggested association in the present case is based on temporal events lacking confirmatory evidence (WHO AEFI causality level “consistent causal association” or demonstration of rising COVID antibody titer.

LETM is defined as the involvement of more than three consecutive vertebral segments. The response to treatment for LETM is variable, with one study showing complete recovery in 41.2% of patients treated with methylprednisolone.[7] Following the introduction of Covid-19 vaccines, reports of transverse myelitis following COVID vaccination have emerged, with very few being longitudinally extensive lesions.[8],[9],[10],[11],[12],[13],[14],[15] The response to steroids[8],[9],[10],[12],[13],[14] or plasmapheresis[11],[14] has been favorable in general with complete or near-complete recovery, although Nakano et al.[15] reported a case of an 85-year-old man who did not respond to immunosuppression. Similarly, in our case, the lady responded dramatically to intravenous steroids. This seems to suggest that although the myelitis associated with the COVID vaccine tends to involve multiple segments, the prognosis seems to be favorable as the response to treatment is robust.


 :: Conclusion Top


To our knowledge, this is the first report of extensive transverse myelitis following ChAdOxx1 nCoV-19 vaccination from India. Transverse myelitis is an uncommon complication following COVID vaccination, which can be longitudinally extensive but shows a good response to immunosuppression.

Declaration of patient consent

The authors certify that appropriate patient consent was obtained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 :: References Top

1.
Voysey M, Clemens SAC, Madhi SA, Weckx LY, Folegatti PM, Aley PK, et al. Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: An interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK. Lancet 2021;397:99-111.  Back to cited text no. 1
    
2.
Akkad W, Salem B, Freeman JW, Huntington MK. Longitudinally extensive transverse myelitis following vaccination with nasal attenuated novel influenza A (H1N1) vaccine. Arch Neurol 2010;67:1018-20.  Back to cited text no. 2
    
3.
Arcondo MF, Wachs A, Zylberman M. Mielitis transversa relacionada con vacunación anti-influenza A (H1N1). Medicina (BAires) 2011;161-4.  Back to cited text no. 3
    
4.
Agmon-Levin N, Kivity S, Szyper-Kravitz M, Shoenfeld Y. Transverse myelitis and vaccines: A multi-analysis. Lupus 2009;18:1198-204.  Back to cited text no. 4
    
5.
Knoll MD, Wonodi C. Oxford–AstraZeneca COVID-19 vaccine efficacy. Lancet 2021;397:72-4.  Back to cited text no. 5
    
6.
Segal Y, Shoenfeld Y. Vaccine-induced autoimmunity: The role of molecular mimicry and immune crossreaction. Cell Mol Immunol 2018;15:586-94.  Back to cited text no. 6
    
7.
Ashfaq MA, Javed I, Arshad M, Yaseen MR. Role of methyl prednisolone in longitudinal extensive transverse myelitis (LETM) in children. Pak J Med Sci 2020;36:451-5.  Back to cited text no. 7
    
8.
Gao JJ, Tseng HP, Lin CL, Shiu JS, Lee MH, Liu CH. Acute transverse myelitis following COVID-19 vaccination. Vaccines (Basel) 2021;9:1008.  Back to cited text no. 8
    
9.
Pagenkopf C, Südmeyer M. A case of longitudinally extensive transverse myelitis following vaccination against Covid-19. J Neuroimmunol 2021;358:577606.  Back to cited text no. 9
    
10.
Notghi AA, Atley J, Silva M. Lessons of the month 1: Longitudinal extensive transverse myelitis following AstraZeneca COVID-19 vaccination. Clin Med (Lond) 2021;21:e535-8.  Back to cited text no. 10
    
11.
Khan E, Shrestha AK, Colantonio MA, Liberio RN, Sriwastava S. Acute transverse myelitis following SARS-CoV-2 vaccination: A case report and review of literature. J Neurol 2022;269:1121-32.  Back to cited text no. 11
    
12.
Hirose S, Hara M, Koda K, Natori N, Yokota Y, Ninomiya S, Nakajima H. Acute autoimmune transverse myelitis following COVID-19 vaccination: A case report. Medicine (Baltimore) 2021;100:e28423.  Back to cited text no. 12
    
13.
Sepahvand M, Yazdi N, Rohani M, Emamikhah M. Cervical longitudinally extensive myelitis after vaccination with inactivated virus-based COVID-19 vaccine. Radiol Case Rep 2022;17:303-5.  Back to cited text no. 13
    
14.
Tahir N, Koorapati G, Prasad S, Jeelani HM, Sherchan R, Shrestha J, Shayuk M. SARS-CoV-2 vaccination-induced transverse myelitis. Cureus 2021;13:e16624.  Back to cited text no. 14
    
15.
Nakano H, Yamaguchi K, Kawabata K, Asakawa M, Matsumoto Y. Acute transverse myelitis after BNT162b2 vaccination against COVID-19: Report of a fatal case and review of the literature. J Neurol Sci 2021;434:120102.  Back to cited text no. 15
    


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