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Título

Spastic paraparesis in a 45-year-old woman post mild SARS-CoV-2 infection

RESUMO

Case Report: We present the case of a 45-year-old woman without previous comorbidities, who sought the emergency unit of our university hospital with a 1-month history of asymmetrical paresthesia in lower limbs, worse in the right side, progressing to both superior limbs after a few days. She had a recent diagnosis of SARS-CoV-2 infection, confirmed through a positive rt-PCR performed ten days before the hospital admission, with mild respiratory symptoms. Along the following week, she presented ascending weakness (worse on the right side), spasticity and weakness in the lower limbs with necessity of a wheelchair and marked constipation. Physical examination at admission evinced: asymmetrical spastic paraparesis with brisk reflexes, ankle clonus and Babinski sign, diminished sense of vibration and proprioception in lower limbs and absence of sensitive level.
We admitted her to the neurology ward, proceeded with brain/whole spine magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) analysis. The MRI did not present any significant alterations and the CSF showed a mild lymphocytic pleocytosis that didn’t remain in further evaluation. Specific autoimmune panels and infectious investigations were negative. The hypothesis of autoimmune myelopathy was made and she received high dose (5g) methylprednisolone for five consecutive days, with poor response. After multiple follow-up MRI scans (1, 2, 5 and 6 months from initial symptoms) and a electroneuromyography with unremarkable findings, we made the diagnosis of MRI-negative post-COVID myelopathy.
Discussion: After COVID-19 pandemic, there have been rare reports of inflammatory myelopathy after SARS-CoV-2 infection. These patients typically had asymptomatic or mild-moderate COVID-19 disease and absence of radiologic evidence of structural spinal cord abnormality, which differs from previous reports that showed myelopathy in hospitalized patients with severe COVID-19 disease and needs of critical care. This is a recently described entity, with only a few reports and unknown pathophysiology and prognosis. Up to date there is no effective treatment described, except rehabilitation.
Final comments: This case adds with prior reports and reinforces the need to increase clinical suspicion in presentations such as this in which there is a compatible epidemiological history and absence of MRI findings and raises the urge for more studies to better comprehension of pathophysiology and possible therapies.