Transverse myelitis following COVID-19 infection or vaccination: Clinical outcomes and imaging characteristics compared with idiopathic cases.

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has revealed various neurological complications, including myelitis. This study examined the clinical and radiological characteristics of transverse myelitis occurring after COVID-19 infection or vaccination.

METHODS

We retrospectively reviewed medical records of patients diagnosed with transverse myelitis between January 2020 and March 2023. Patients were categorized into post-COVID-19 infection transverse myelitis (PITM), post-COVID-19 vaccination transverse myelitis (PVTM), or idiopathic transverse myelitis (ITM). Clinical and radiological characteristics were compared among groups.

RESULTS

Patients with PITM had more severe deficits, presenting with a higher median modified Rankin Scale (mRS) score at hospitalization (5.0) than PVTM (3.0, p = 0.003) and ITM (2.0, p = 0.001). At six months, good functional outcomes (mRS ≤1) were least frequent in PITM (23.1 %) compared with PVTM (50.0 %) and ITM (73.9 %, p = 0.013). PITM showed more extensive spinal cord lesions (median: 14.0 segments) than PVTM (4.0, p = 0.029) and ITM (2.0, p = 0.001), and more multifocal axial lesions (75.0 %, p < 0.001). Bilateral corticospinal tract involvement extending to the internal capsule was observed only in PITM (n = 3). MRI-negative myelitis was identified in one PITM and one PVTM case. Treatment escalation to IVIG, plasmapheresis, or immunosuppressants was more frequently required in PITM (69.2 %) than in PVTM (25.0 %) or ITM (8.7 %, p = 0.001).

CONCLUSIONS

PITM is associated with more severe deficits, extensive spinal cord involvement, and poorer outcomes than PVTM and ITM. Features such as bilateral corticospinal tract lesions and MRI-negative presentations may help distinguish COVID-19-related myelitis subtypes. Early recognition and timely escalation of immunotherapy are essential for improving outcomes in COVID-19-related myelitis.