Multiple Sclerosis and Neuromyelitis Optica Spectrum Disorder: Onset Following Acute COVID-19 Infection, a Case Series

Abstract

Background and Objectives: Acute COVID-19 infection has been associated with neurological involvement. We report a case series of newly diagnosed patients with multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) developed in a short period of time after acute COVID-19 infection. Methods: New MS patients developing initial symptoms shortly after an acute COVID-19 infection were diagnosed based on the 2017 McDonald Criteria [Garcia-Ramos et al. in Cells, 2021]. The patients diagnosed with NMOSD met the 2015 International Panel criteria for the diagnosis of NMOSD (IPDN) [Thompson et al. in Lancet Neurol 17:162-173, 2018]. Results From the MS Patient Group: Ten patients were included who had developed initial MS symptoms after COVID-19 infection. Gender distribution was equal (50% male). The mean age was 28 (range 17-39) years. Average time to neurological presentation was between 2 and 6 weeks following acute COVID-19 infection. Partial transverse myelitis was the initial presentation in 40% of the cases, and 60% of patients had spinal cord lesions present at the moment of diagnosis. All patients showed enhancing lesions on brain magnetic resonance imaging (MRI). The presence of cerebrospinal fluid (CSF) oligoclonal bands was found in all six tested cases. The majority of patients (80%) were unvaccinated for COVID-19. The two vaccinated patients had received two doses of the monovalent COVID-19 messenger ribonucleic acid (mRNA) (Pfizer Biotech) vaccine and no booster, a year prior to contracting COVID-19.Results From the NMOSD Group: Two patients with NMOSD were included. Positive aquoporin-4 protein antibody (AQP-4 Ab) was detected in serum in both cases [one Enzyme Linked immunosorbent assay (ELISA) and one cell based]. Both patients had mild COVID-19 infection prior to presentation, initial neurologic symptoms presented between 3 and 6 weeks after COVID-19 infection. Neither patients were vaccinated. Both responded partially to steroids, one developed a relapse 40 days after diagnosis. Conclusion: COVID-19 infection has been linked to several neurological and immune-driven conditions. This study suggests that in susceptible individuals, acute COVID-19 infection may act as a trigger for developing MS and NMOSD.

COVID-19 and the risk of neuromyelitis optica spectrum disorder: a Mendelian randomization study

“…The use of the most comprehensive COVID-19 phenotype data to date by Baranova et al. makes their findings more reliable and consistent with certain case reports or case series observations ( 6 , 42 , 43 ).…”

The Potential Role of SARS-CoV-2 Infection and Vaccines in Multiple Sclerosis Onset and Reactivation: A Case Series and Literature Review

“…Both from our experience and a review of the cases reported in the literature, viral/vaccine exposure is more strongly associated with MS onset than with disease reactivation [ 49 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 ]. The most plausible explanation is the protective effect of DMTs against the inflammatory activation of the immune system known to be triggered by viral infection/vaccination.…”

“…Even though it is impossible to attribute a definite causal role for MS onset to SARS-CoV-2 and the related vaccines, several cases have been reported both after COVID-19 (8 case reports, 3 case series, Table 1 ) and after anti-SARS-CoV-2 vaccines exposure (13 case reports, 6 case series, Table 2 ) [ 49 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 ]. Cases of post-viral infection MS onset or relapse presented with clinical symptoms suggestive for demyelinating disorders after a few days to 6 weeks from viral exposure, except for one case in which the viral infection preceded the disease onset by 6 months [ 58 ].…”

“…The first clinical symptoms suggestive for MS were related to the infratentorial regions (four cases with diplopia, one case with facial palsy and one case with nystagmus and ataxia), the optic nerve (two cases) or the spinal cord (two cases of bilateral sensory symptoms). In the case series published by Avila et al [ 59 ], 20% of pwMS presented with symptoms related to brainstem impairment, 40% with optic neuritis and the remaining 40% with symptoms attributable to the spinal cord. With respect to the two published cases of MS reactivation after viral exposure, one presented with unilateral motor symptoms and one with bilateral sensory symptoms attributable to a documented lesion within the spinal cord.…”

A case study: ADEM-like lesions as a first clinical event in highly active multiple sclerosis

“…development after COVID-19 in unvaccinated patients(Avila et al, 2023;Pignolo et al, 2021;Palao et al, 2020). A systematic review found 18 cases of MOGAD following infection(Mirmosayyeb et al, 2023), while another one revealed 15 cases of NMOSD(Harel et al, 2023).…”