Longitudinally Extensive Transverse Myelitis (LETM) and Myopericarditis in a 7-Month-Old Child with SARs-CoV-2 Infection

Abstract

Introduction In the last few months, some pediatric cases with neurological and neuroradiological pictures related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections have been reported, often associated with multisystem inflammatory syndrome (MIS-C). The most frequently encountered pediatric neurological complications seem to be postinfectious immune-mediated acute disseminated encephalomyelitis (ADEM)-like changes of the brain, myelitis, neural enhancement, and splenial lesions. Concomitant neurological and cardiac involvement has been reported only in MIS-C, although specific clinical details are often not fully available.

Methods In this case report, a very young child infected with SARs-CoV-2 and diagnosed as longitudinal extensive transverse myelitis with concomitant myo-pericarditis is presented.

Results A previously healthy 7-month-old girl presented with abrupt onset of generalized weakness with inability to sit up. She had had mild respiratory symptoms 1 week earlier. Spinal magnetic resonance imaging (MRI) showed a T2-hyperintense intramedullary lesion extending from C4 to T2, compatible with acute longitudinally extensive transverse myelitis (LETM). Cerebrospinal fluid analysis was negative.

Echocardiography and blood tests were suggestive for myo-pericarditis. Real time polymerase chain reaction for SARS-CoV-2 on nasopharyngeal swab sample tested positive. She was promptly treated with high dose of steroids and immunoglobulin with satisfactory clinical response.

Conclusion To the evolving literature of neurological complications of SARs-CoV-2 infection, we add the youngest patient described to date with isolated LETM and concomitant cardiac involvement. Our case suggests that clinicians should be aware of this association, although difficult to recognize in infants. Practitioners are encouraged to consider aggressive first-line immunotherapies with the final aim to prevent permanent disability.

Keywords

longitudinally extensive transverse myelitis - demyelination - COVID-19 - myopericarditis

Publication History

Received: 15 April 2021

Accepted: 10 June 2021

Article published online:
29 July 2021

• References

• 1 Feldstein LR, Rose EB, Horwitz SM. et al; Overcoming COVID-19 Investigators, CDC COVID-19 Response Team. Multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med 2020; 383 (04) 334-346
• 2 Paterson RW, Brown RL, Benjamin L. et al. The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings. Brain 2020; 143 (10) 3104-3120
• 3 Kaur H, Mason JA, Bajracharya M. et al. Transverse myelitis in a child with COVID-19. Pediatr Neurol 2020; 112: 5-6
• 4 Lindan CE, Mankad K, Ram D. et al; ASPNR PECOBIG Collaborator Group. Neuroimaging manifestations in children with SARS-CoV-2 infection: a multinational, multicentre collaborative study. Lancet Child Adolesc Health 2021; 5 (03) 167-177
• 5 Abrams JY, Godfred-Cato SE, Oster ME. et al. Multisystem inflammatory syndrome in children associated with severe acute respiratory syndrome coronavirus 2: a systematic review. J Pediatr 2020; 226: 45-54.e1
• 6 Scott TF, Frohman EM, De Seze J, Gronseth GS, Weinshenker BG. Therapeutics and Technology Assessment Subcommittee of American Academy of Neurology. Evidence-based guideline: clinical evaluation and treatment of transverse myelitis: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2011; 77 (24) 2128-2134
• 7 Ellul MA, Benjamin L, Singh B. et al. Neurological associations of COVID-19. Lancet Neurol 2020; 19 (09) 767-783
• 8 Brisca G, Siri L, Olcese C, Brunenghi BM, Pirlo D, Mancardi MM. Is SARS-CoV-2 infection a risk for potentiation of epileptic seizures in children with pre-existing epilepsy?. Pediatr Neurol 2021; 116: 31
• 9 Swarz JA, Daily S, Niemi E, Hilbert SG, Ibrahim HA, Gaitanis JN. COVID-19 infection presenting as acute-onset focal status epilepticus. Pediatr Neurol 2020; 112: 7
• 10 Keyhanian K, Umeton RP, Mohit B, Davoudi V, Hajighasemi F, Ghasemi M. SARS-CoV-2 and nervous system: from pathogenesis to clinical manifestation. J Neuroimmunol 2020; 350: 577436
• 11 Wolf VL, Lupo PJ, Lotze TE. Pediatric acute transverse myelitis overview and differential diagnosis. J Child Neurol 2012; 27 (11) 1426-1436
• 12 Lindner D, Fitzek A, Bräuninger H. et al. Association of cardiac infection with SARS-CoV-2 in confirmed COVID-19 autopsy cases. JAMA Cardiol 2020; 5 (11) 1281-1285
• 13 Alsaied T, Tremoulet AH, Burns JC. et al. Review of cardiac involvement in multisystem inflammatory syndrome in children. Circulation 2021; 143 (01) 78-88
• 14 Bodro M, Compta Y, Sánchez-Valle R. Presentations and mechanisms of CNS disorders related to COVID-19. Neurol Neuroimmunol Neuroinflamm 2020; 8 (01) e923
• 15 Ghraichy M, Galson JD, Kovaltsuk A. et al. Maturation of the human immunoglobulin heavy chain repertoire with age. Front Immunol 2020; 11 (11) 1734