SARS-CoV-2 is a neurotropic virus. Neurological manifestations following the infection are well documented. Postvaccination Guillain‒Barre syndrome, possibly as a result of immune-mediated attack on myelin, is also well documented. However, selective involvement of tracts in the nervous system following COVID-19 vaccine has not been reported so far.
A 46-year-old male presented with acute-onset weakness, tingling, and numbness in both lower limbs, along with and retention of urine for 7 days. The patient had taken the first dose of Covishield vaccine 6 days before the onset of symptoms. There was no history of fever or cough preceding the illness. The general examination was unremarkable. The patient had normal higher mental functions. The cranial nerves and speech were normal. Both upper limbs were normal on examination. Power was grade 0/5 in both lower limbs. Deep-tendon jerks were brisk in both lower limbs and both planter reflexes showed extensor response. Pain and temperature sensations were normal. Joint position and vibration were impaired to the anterior superior iliac spine. The patient had a Foley’s catheter in situ. Routine hematological parameters, serum Vitamin B12, renal function tests, liver function tests, reverse transcriptase polymerase chain reaction (RT-PCR) for COVID-19, serum myelin-associated glycoprotein antibodies, aquaporin-4 antibodies, HIV, HbsAg, anti-hepatitis c virus (HCV) antibodies, and antinuclear antibodies were negative. Cerebrospinal fluid examination (CSF) showed two cells, 33 mg% proteins, and sugar of 60 mg%. Serum COVID-19 antibody titer by chemiluminescent microparticle immuno assay (CMIA) was 5.7 (positive). CSF RT-PCR for COVID-19, COVID antibodies, and oligoclonal bands was negative. Magnetic resonance imaging (MRI) of the spine revealed nonenhancing T2 and flair hyperintensities selectively involving only posterior column and lateral corticospinal tracts and sparing other tracts extending throughout the entire length of the spinal cord [Figures 1 and 2]. MRI brain revealed bilateral symmetrical nonenhancing T2 and flair hyperintensities involving the posterior part of the posterior limb of the internal capsule which could be traced to the anterior part of the tegmentum of the midbrain [Figures 3-6] which is the location of corticospinal tracts. The patient was started on injection methylprednisolone pulse therapy, followed by seven cycles of plasmapheresis; however, there was no improvement in his neurological status.
GuillainBarre syndrome following any vaccination is believed to be immune mediated. Similar mechanism of molecular mimicry and COVID antibodies attacking myelinated tracts in the central nervous system (CNS) is postulated. Post-COVID-19 vaccine transverse myelitis has been reported.[2,3] One case report of post-COVID tract-specific CNS involvement has been described from India, where the patient had only involvement of the corticospinal tracts and posterior columns like in our present case. There is no plausible explanation as to why only these two tracts are selectively involved (both COVID-associated and post-COVID vaccine) apart from the fact that both of these tracts are heavily myelinated. To the best of our knowledge, this is the first such case reported after COVID-19 vaccine.
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