SARS-CoV-2 vaccinations complicated by transverse myelitis.

We read with interest the article by Maroufi et al. about a 31 years old female who was diagnosed with transverse myelitis 5 weeks after the first dose of the Astra Zeneca vaccine.1 Various alternative causes were excluded and the patient was treated with steroids, which resulted in incomplete remission of paraparesis and sphincter dysfunction at the 3 months follow-up.[1] The study is appealing but raises concerns that need to be discussed.

The latency between vaccination and onset of symptoms was 21 days, thus fairly long. Therefore, the cerebrospinal fluid (CSF) should have been investigated for alternative viral or bacterial infections. Particularly excluded should have been an infection with human immunodeficiency virus (HIV), varicella zoster virus (VZV), Epstein Barr virus (EBV), hepatitis viruses, herpes simplex virus (HSV), and a bacterial infection with Mycobacterium tuberculosis. A negative nasal swab PCR test for SARS-CoV-2 not necessarily excludes an infection with SARS-CoV-2. We should know if the CSF was also negative for SARS-CoV-2.

Missing is an investigation of the CSF for cytokines, chemokines, and glial factors. Previous studies have shown that central nervous system (CNS) involvement in SARS-CoV-2 infections as well as neurological compromise following a SARS-CoV-2 vaccination can be associated with elevation of interleukines and chemokines.[2,3]

Another limitation is that no cerebral MRI had been carried out to exclude or confirm concomitant cerebral lesions.

Transverse myelitis as a complication of SARS-CoV-2 vaccinations is not infrequent. It has been previously reported in at least 16 patients as a complication of a SARS-CoV-2 vaccination (Table 1). Age of these ranged between 23 and 85y. Eight were males. Latency between vaccination and onset of myelitis ranged from 1d to 21d (Table 1). All patients received steroids, some additional plasma exchange, and one additional immune-adsorption (Table 1). Only two patients achieved a full recovery at the last follow-up. One patient died.

Table 1.

Patients with transverse myelitis following a SARs-CoV-2 vaccination and exclusion of alternative causes.

Age	Sex	Brand	Latency	Treatment	Outcome	Reference
23	f	BPV	21	steroids	IR	[4]
81	m	BPV	3d	steroids	IR	[4]
26	f	BPV	2d	steroids	IR	[5]
85	m	BPV	1d	steroids	FO	[6]
75	m	BPV	3d	steroids	IR	[7]
36	m	AZV	8d	steroids	CR	[8]
63	m	MOV	2d	steroids	CR	[9]
45	m	AZV	8d	steroids	IR	[10]
41	m	AZV	14d	steroids	IR	[11]
25	f	AZV	16d	steroids	IR	[12]
76	f	MOV	6d	steroids	IR	[13]
58	m	AZV	10d	steroids, PE	IR	[14]
67	f	MOV	1d	steroids, PE	IR	[15]
44	f	JJV	7d	steroids, PE	IR	[16]
78	f	SVV	3d	steroids	ÎR	[17]
40	f	AZV	14d	steroids, PE	IR	[18]
				IAD

AZV: Astra Zeneca vaccine, BPV: Biontech Pfizer vaccine, CR: complete recovery, FO: fatal outcome, IAD: immune adsorption, IR: incomplete recovery, JJV: Johnson and Johnson vaccine, MOV: Moderna vaccine, PE: plasma exchange, SVV: Sinovac vaccine.

We do not agree that only 254 patients with neurological complications following a SARS-CoV-2 vaccination have been reported.[1] In a recent review about the neurological side effects of SARS-CoV-2 vaccination almost 4000 patients with neurological complications have been reported as per the end of September 2021.[19] The most frequent of the neurological side effects were headache, venous sinus thrombosis (VST), and Guillain Barre syndrome (GBS). The number of neurological side effects is presumably much higher since this study did not include patients with hypogeusia/dysgeusia or hyposmia/dysosmia and as not all patients with neurological side effects were also published

Another limitation is that the patient was not investigated for thyroid dysfunction.

We should be informed why it took 14 days after onset of symptoms that the patient visited the doctor.

Overall, the interesting study has some limitations which challenge the results and their interpretation. Addressing these limitations would strengthen the conclusions and could result in more precise advice how to manage patients with SARS-CoV-2 vaccination associated transverse myelitis.