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Título

Post-COVID19 Acute Transverse Myelitis treated with plasma exchange and Rituximab: a case report.

RESUMO

CASE REPORT: 51-year-old woman with severe obesity and no other medical history, admitted with dyspnea and anosmia for 5 days. SARS-COV-2 pneumonia was confirmed by RT-PCR. The patient developed respiratory distress within 24 hours and required mechanical ventilation for 4 days, without hemodynamic instability. After pulmonary recovery the patient noticed difficulty in standing, received discharge in a wheelchair. At home, progressively worsens motor function, not being able to support her trunk associated with bladder dysfunction and lower limb paresthesia. Readmitted 15 days after, the first neurological examination described severe muscle weakness of lower limbs, feet drop and mild involvement of intrinsic hands muscles; global deep tendon absence and babinski sign bilaterally; large and small fiber anesthesia below T12 level. Spine MRI concluded transverse myelitis from C7 to T12; CSF's routine was normal and RT-PCR for SARS-COV-2 and Herpesviruses went negative. Investigation for neuroimmune and rheumatologic markers, serological status, onconeural antibodies, hypovitaminosis and metabolic causes were negative. Methylprednisolone 1g for seven days was administered with poor motor outcome. Afterwards, seven plasma exchange sessions followed by Rituximab 2g total dose led to substantial improvement. At deinstitutionalization the patient regained bladder and trunk control with poor lower limb mobility. At three-month follow-up the patient could sustain her legs; at sixth month she could walk with crutches. Nine months after discharge she could walk without assistance. DISCUSSION: Acute Transverse Myelitis (ATM) is a rare and acquired neuro-immune disorder characterized by perivascular lymphomononuclear infiltration of spinal cord affecting white and gray matter, explaining sensitive, motor and autonomic dysfunctions. Besides it’s difficult to assuredly exclude differential diagnosis, post-viral infection immune-mediated TM is a main etiology, classically associated with the human Herpesviruses. Nethertheless, as described in other reports, immune-mediated TM is an emerging complication of SARS-COV-2 infection, which by analogy, has been treated how other viruses justifying an immunosuppressive therapy. FINAL COMMENTS: Albeit evidence is needed to guide decision through post-COVID19 TM, this case corroborates for an combined aggressive immune-therapy after a suitable investigation for severe presentations with high rate of disability and complications.