1107 - Incomplete Paraplegia Secondary to Post-COVID-19 Subacute Myelitis: A Case Report

Case Diagnosis: Incomplete Paraplegia Secondary to Post-COVID-19 Subacute Myelitis

Case Description: A 79-year-old male presents with progressive bilateral lower extremity weakness and difficulty rising from a seated position, three weeks after recovery from COVID-19. His symptoms progressed to urinary retention, fecal incontinence, and sensory disturbances. Physical examination revealed decreased strength and sensation below the T9 level, with ASIA Impairment Scale B. Cerebrospinal fluid analysis was unremarkable. Spinal MRI showed no compressive or inflammatory lesions. He was treated with high-dose intravenous corticosteroids followed by intravenous immunoglobulin (IVIG), and admitted to a spinal cord injury rehabilitation unit for intensive physical therapy.  After treatment, recovery remained delayed, with significant gait impairment and persistent neurogenic bladder requiring intermittent catheterization (IC). However, at ten months post-onset, he began to improve motor function and no longer required IC, indicating a delayed yet ongoing recovery trajectory.

Discussions: The clinical picture is consistent with subacute, post-infectious transverse myelitis (TM) following COVID-19, a diagnosis supported by the temporal relationship of infection, characteristic neurological deficits, and exclusion of alternative causes. This case not only illustrates a rare neurological complication of COVID-19, but also a delayed recovery trajectory in post-COVID TM. Unlike idiopathic TM, where most neurological recovery occurs within 1–3 months, post-COVID TM may exhibit a slower and prolonged recovery. Emerging evidence suggests immune-mediated mechanisms, such as cytokine dysregulation, contribute to sustained neurological deficits.

Conclusions: Post-COVID TM may follow a delayed and slower recovery course compared to idiopathic TM, with functional improvements extending beyond six months. Clinicians should maintain a high index of suspicion for post-infectious myelopathy in patients with new-onset myelopathic symptoms following COVID-19, even in the absence of MRI or CSF abnormalities. Early initiation of corticosteroids, immunotherapy, and rehabilitation is critical for optimizing outcomes. A multidisciplinary care and long-term follow-up are essential to support functional recovery and improve quality of life in affected patients.