Disclosures: Michael Schmidt, MD: No financial relationships or conflicts of interest

Case Diagnosis: Lupus patient develops transverse myelitis status post COVID-19 infection

Case Description: A 24-year-old female with history of lupus, GERD, COVID (one year prior), presented with bilateral lower extremity weakness for one day, “penguin walking”, paresthesia below the waist, fever, chills, and diarrhea.

Setting: Acute Rehabilitation, Community Hospital – Brooklyn, NY

Assessment/Results: Initially, patient’s temperature was 102.7F. Sensation was intact, strength was decreased in right more than left lower extremity. Labs were positive for ANA, dsDNA, Smith, and RNP antibodies. Lumbar puncture showed elevated WBC, neutrophilia, increased IgG, and elevated protein: albumin ratio. MRI demonstrated ill-defined spinal cord areas of signal alteration at T2, T4, and T10-11 suggestive of transverse myelitis/lupus myelitis. Symptoms improved after steroids, and cyclophosphamide drip. During her rehabilitation course, lower extremity strength, ambulation, and endurance returned to baseline. Daily plaquenil and prednisone continued as well as outpatient cyclophosphamide monthly for 4 months.

Discussion: Systemic lupus erythematosus (SLE), is rarely associated with transverse myelitis (TM). It occurs in 1-2% of patients within the first 5 years of SLE and reoccurs in 18-50%. Often, TM involves 3 or more contiguous spinal levels. The pathophysiology of TM in lupus is believed to be caused by thrombosis of the small vasculature supplying the thoracic spinal cord. Post-COVID hypercoagulable states could increase the risk. Motor involvement is usually bilateral, with spastic paraparesis being the most common. T5 to T8 are most frequently affected. T2 MRI signal intensity with spinal cord swelling, in the cervical or thoracic regions, is the gold standard test to confirm TM. A combination of methylprednisolone and cyclophosphamide is recommended.

Conclusion: Transverse myelitis should be considered in lupus patients presenting with fever and a new or recurrent neurologic deficit. Radiologic findings present contiguously in the thoracic spinal cord and are less commonly discontiguous as in our patient. Early diagnosis and treatment are essential to achieve the best outcome.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/a-rare-case-of-lupus-transverse-myelitis-in-a-post-covid-19-patient/