Abstract
Background Acute MRI-positive transverse myelitis is a well documented post-infectious phenomenon following SARS-CoV-2 infection. There are reports of MRI-negative presentations of myelitis following SARS-CoV-2 infections.
Methods Between September and December 2022, three patients presenting to hospitals in the Auckland region, New Zealand, were prospectively followed by the authors. Their clinical features are outlined. A literature search for patients with MRI-negative myelitis/myelopathy following SARS-CoV-2 infection was conducted.
Results We document three patients with initially negative MRI who presented with symptoms and signs of myelopathy – progressive paraparesis with significant gait disturbance, impaired proprioception, Lhermitte’s phenomenon, sensory level, hyperreflexia and spasticity. Despite treatment with corticosteroids, all patients had progression of symptoms. Ten further patients with initial normal MRI of the spinal cord have been described in the literature. The mean age was 58, and 7 were women. The onset of symptoms ranged from 1 to 16 weeks after SARS-CoV-2 infection. All patients had lower limb onset of symptoms, with 10 developing paraparesis. Nearly all had significant dorsal column involvement, often with sensory ataxia. Our 3 patients exhibited early Lhermitte’s phenomenon as a distinctive feature. Most patients had hyperreflexia and a sensory level. Treatment was most commonly with intravenous methylprednisolone, with rare improvement.
Conclusions Due to the novel description of these patients alongside the absence of initial MRI findings, the diagnosis can easily be overlooked. We propose these patients have a distinct syndrome of COVID-19 MRI-negative myelopathy.
