Acute transverse myelitis associated with Covishield Vaccine: A case report

The patient included in this case study, Kavita Muthe, is from the Ahmednagar district’s Shrirampur hamlet. She is 36 years old, weighs 70 kg, is 162 cm tall, works as a homemaker, and has two children. After receiving the Covishield immunization two years prior, she had low back pain and lower extremity numbness. She visited the village doctor, who gave her some temporary medication.

Her legs began to hurt and become weak immediately af ter the immunization, and the next day she developed a strong headache. She was admitted to the intensive care unit’s emergency department. Investigations included MRI results, hematology, and biochemistry, which involved a CSF protein test. The results of the MRI investigation pointed to acute spinal cord inflammation. The results of the biochemistry tests were generally conventional, with the exception of the CSF protein results, which were highly aberrant. Immediate Transverse Myelitis caused by immunization was confirmed by a combination of a high abnormal protein test and acute spinal inflammation.

Introduction

We are noticing an upsurge in negative vaccination reactions when the coronavirus (COVID-19) vaccines are administered globally (AEFI). The AEFI linked to the COVID-19 vaccines produced by Pfizer-BioNtech, Moderna, and Johnson and Johnson has been reported by the Centers for Disease Control (CDC). Among these AEFI are neurological side effects, which might include stroke and facial palsy. The majority of adverse reactions following vaccination are non-specific systemic symptoms, among which the neurological symptoms include paresthesia, paresthesia, headache, dizziness, pain, and muscle spasms. On incredibly rare occasions, tremors, dysphonia, diplopia, tinnitus, convulsions, and herpes zoster recurrence have all been noted [1,2]. Acute disseminated encephalomyelitis, stroke, Guillain-Barré syndrome, Bell’s palsy, transverse myelitis, and Bell’s palsy are some further severe neurological disorders.

Case description

A 36-year-old lady reported acute right-sided back pain that began gradually and was located lateral to the thoracic spine at T4. Since the previous evening, she had gradually developed bilateral paresthesia and numbness in her legs, making it difficult for her to move. Prior to five days, she received her first dosage of the COVID-19 vaccine (Covishield), which was followed by a two-day period of fatigue, fever, chills, and headaches. After initially getting better, symptoms returned to their previous state on day eight, including chills, a new headache, thoracic back discomfort, and general weakness.

After initially improving, symptoms including chills, a new headache, thoracic back pain, and general weakness returned to their prior state on day eight.

While urinary retention necessitated the placement of a catheter, motor or sensory impairment may be objectively identified at the initial neurologic examination. There were no signs of a widespread infection, like a fever. A nasopharyngeal swab yielded negative SARS-CoV-2-RT-PCR results.

Initial testing revealed low levels of hemoglobin at 8.5 g/dL (12.0-15.5 g/dL), hematocrit at 27% (normal values are 36%-48%), platelet counts at 1,30,000/uL (150,000-450,000/uL), calcium at 8.4 mg/dL (8.6-10.3 mg/dL), total protein at 5.8 g/dL (6-8.3 g/dL), albumin at 3.2 g, D-di.

When she came, she was sleepy but awake, and afebrile, and her vital signs were stable. Physical examination findings revealed that the cranial nerves were still in good condition, and the Medical Research Council (MRC) assessed the motor strength as 0/5 in the right and left lower extremities and 4/5 in the right and left upper extremities.

The patient had an unremarkable brain CT done. On brain scans (Mild Contrast Enhancement) MRI of the cervical spine, areas along the cortical Sulci that are FLAIR hyperintense suggested generalized cerebral edoema. Changed Signal Intensity in Bulky Spinal Cord with Diffuse. Diffuse posterior bulging causing a significant subarachnoid space depression at the C5-C6 intervertebral disc. More research has been done to determine the causes.

The patient received daily 1 g IV solumedrol (IVMP) dosages for three days. After receiving IV solumedrol, the patient’s health did not improve, therefore plasmapheresis (PLEX) therapy was commenced for a five-day period. The patient got physical therapy on day 5 after being admitted, and by then she had improved in both her weakness and strength. After that, she was transferred to a recovery center.

When she was released from the hospital, she was ambulating with a rolling walker, and imaging (MRI and CT) prescribed rehabilitation (PT) for the patient. She mostly complained of tingling, numbness, and weakness in both anterior LEs, as well as in the rear of her left leg and all the way to her toes, with her right LE exhibiting these symptoms more frequently than her left LE. She also displayed the same symptoms on the right side of the abdomen. The patient also mentioned having lower back pain while sleeping supine, which interfered with her ability to walk. Each symptom becomes more severe over time. Prednisone was administered to the patient to treat the TM, and Tylenol to treat back discomfort.

Examination

While receiving care at Pravara Medical Trust, the patient was unable to discriminate between hot and cold feelings on her feet during a neurological screening. She did not specify whether any additional sensation testing had been conducted or the results of those tests, however. The patient got exceedingly weary during the assessment due to the nature of TM. Therefore, some changes were required for all assessments in order to allow the patient to conserve energy. The focus of the assessments was on muscle power, gait, pain, and range of motion (ROM). The strength of the UE and LE muscles. The results of the muscle strength test showed that the patient’s lower extremities on both sides were weak. The patient was less able to carry out daily chores as a result of this loss of strength. This drop in strength affected the patient’s functional capacity to perform activities of daily living (ADLs), such as walking and transfers [3-5].

Intervention

The primary goal of the PT intervention was to increase functional movement and mobility, but it was also crucial to take into account how much fatigue the patient was experiencing and could tolerate throughout each treatment session. The topic of energy conservation was covered. Include passive ROM in your training regimen, including hip flexion, neutral hip extension, knee flexion, extension, ankle dorsi-flexion, plantar flexion, inversion, and eversion. The therapist performed the passive ROM exercises with the patient seated and supine after the patient had finished the active ROM exercises. The primary goal of the PT intervention was to increase functional movement and mobility, but it was also crucial to take into account how much fatigue the patient was experiencing and could tolerate throughout each treatment session. The topic of energy conservation was covered. Include passive ROM in your training regimen, including hip flexion, neutral hip extension, knee flexion, extension, ankle dorsi-flexion, plantar flexion, inversion, and eversion. The therapist performed the passive ROM exercises with the patient seated and supine after the patient had finished the active ROM exercises.

Gait training was done during the final therapy session as the patient gained exercise stamina during the course of treatment. The usage of assistive aids occurred during gait training [6-8]. Along with suitable sleeping support, which entails placing cushions under the knees to reduce low back pain, the patient also received instruction on proper shoe wear, which attempts to improve walking mechanics and protect the feet.

The patient found the PT program very helpful, particularly the exercise program, which boosted her daytime endurance, in her subjective opinion. She did mention that on other days with more activity, she would say that towards the end of the day, she would feel exhausted and drained. In order to help the patient recuperate from the diagnosis at the time she was being examined, corticosteroids (Prednisone) were recommended. The patient showed an improved tolerance for physical exercise over the course of two weeks. The patient added that she was able to feel the warmth and chilly when she arrived at therapy in the later weeks of treatment.

Discussion

The case demonstrates a close temporal correlation between COVID-19 immunization and the symptoms, which appeared and got worse within a week of the first dosage of the vaccine. Before this presentation, the patient did not exhibit any symptoms of COVID-19 infection, and there were no COVID-19 antibodies found in the patient’s serum. After receiving the COVID-19 vaccine, the acute transverse myelitis attack started within a week, and on the 12th day, it started to worsen. An evidence-based physical therapy assessment and treatment plan for a female patient with TM, age 36, were reported in this case report. The PT plan of care was useful to improve the patient’s clinical complaints, according to subjective and objective evaluations. The literature suggests that the rehabilitation strategy for acute TM should be activity-based and highlight impairment, despite the fact that there is relatively little clinical evidence on the condition.

Functional tasks and movements, such as passive and active ROM exercises, strengthening exercises, joint mobilizations when needed, and neuromuscular re-education, must be incorporated into the physical therapy treatment. By breaking down each functional activity, the PT treatment plan in this case study was appropriately customized to the patient’s situation of extreme exhaustion. One of the most prevalent symptoms of TM is fatigue. Therefore, throughout PT treatment, it is important to stress education, especially energy-saving strategies. Furthermore, because patients with TM may tire easily, complex functional tasks might not be appropriate for them. Physical therapists may need to divide a single functional movement into numerous acts when prescribing therapeutic exercise. They should also explain to patients how each exercise will be useful and applicable to activities of daily living. The rehabilitation team decided to start with therapies aimed at better functional mobility right once. We were able to concentrate our treatment sessions on tasks that required our help and expertise by giving the Patient a home exercise program to do on her own. While breaking down movements can be helpful, we felt that helping our patient with bigger capacity movements would be more beneficial given the little amount of time we had with her. If we had more time, we might have chosen a different strategy for recuperation [9-12].

Conclusion

As the COVID-19 pandemic’s neurologic effects continue to spread, vaccine-related diseases are coming to light. In order to make a more accurate assessment of the actual relevance and potential risk, thorough reporting is undoubtedly required. If such instances become more significant, we will need to do a thorough risk-benefit review to decide how to proceed with vaccines. Given that widespread vaccination is now the most effective method of combating this pandemic, the rarity of such an incident shouldn’t discourage people from using vaccines.

It’s crucial to take into account any changes that may have been made to have provided better patient care in any circumstance.

Increased wheelchair training duration and intensity ought to have been taken into account. Increased wheelchair training is supported by a wealth of literature on rehabilitation. In order to increase freedom in the community and decrease injury, new manual wheelchair users consider proper propulsion techniques, rough terrain navigation, and curb navigation as crucial skills. Advanced wheelchair skills are also linked to lower injury risk, better social integration, and higher quality of life.

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