#MSCOVID19: transverse myelitis

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Barts-MS rose-tinted-odometer: ★★

How do you distinguish transverse myelitis that is not MS-related from spinal cord involvement in MS? 

Yesterday after reporting the possible and likely link between the Oxford-AstraZenca vaccine and transverse myelitis (TM) and possibly MS you asked how do neurologists differentiate TM from CIS or MS. 

Idiopathic or post-infectious/vaccine-related TM tends to be more extensive, i.e. involve multiple segments of the spinal cord compared to CIS/MS. This is often referred to as longitudinally-extensive TM. In addition, typical non-MS TM tends to involve the whole cord and not particular areas of the spinal cord. In comparison, CIS/MS tends to have discrete lesions that may involve the back or a segment of the spinal cord and extend over one or two segments. 

CIS/MS myelitis tends to fit the demographic profile of MS, i.e. more common in females, youngish age of onset (20-40 years) and is more common in regions of the world with a high MS prevalence. In addition, there are often other lesions in the brain and/or spinal cord that look like MS and CSF analysis usually shows oligoclonal IgG band and the cell counts in the spinal fluid are lower. 

Non-MS related TM can occur in any age group, occurs in both sexes and its quite common in Asian, African, Afro-Caribbean and African-American populations.  Brain imaging is usually normal; the exception being some patients with NMO. CSF analysis is OCB negative and the cell count is often raised. Interestingly, it is not uncommon in acute TM to find some neutrophils and occasionally eosinophils in the spinal fluid that does not happen in MS-related myelitis. 

An important clue is that non-MS related TM may have obvious precipitating factors of a recent viral or bacterial infection or vaccination. 

Saying all this it is sometimes very hard to differentiate the two and then time becomes the best diagnostician, i.e. you have to wait to see if someone goes onto to develop recurrent events. This is why medicine and neurology remain as much an art as a science. 

Worryingly the number of TM cases post-COVID-19 in the literature is quite high considering we are only 6-9 months into this pandemic. This would indicate that SARS-CoV-2 and its proteins may be the triggering factor for TM and/or MS and this will make this adverse event from this vaccine a real problem and we are likely to see more cases emerge. This does not mean the vaccine won’t be effective it simply means that some people with have to suffer harm to protect the many or the herd. This is the basic premise that population health is based on. 

CoI: multiple

Twitter: @gavinGiovannoni  / Medium: @gavin_24211

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.

30 comments

  • Can TM mimic MS by showing a number of T2 (or even a T1) lesion on diagnosis?

    (only asking since my first ever symptoms of pins+needles and optic neuritis appeared less than 30 days after a Hep. B vaccine at the Soho clinic…)

  • hiya prof g i have tried to contact you a few times regarding my recent health situation. in a brief overview in march i had a recurrent fever breathing difficulties and cough as well as heavy fatigue and vision issues. i started to feel better other than vision issues. mid April i woke up to numb feet which over the space of two weeks spread up to my neck. i was hospitalized and given an mri and a lumbar puncture. i had three days of steroids and diagnosed with ms. this is where it gets interesting the neuro that diagnosed didn’t have my lp results when diagnosing me and did not take into account the recent obvious viral illness be it covid 19 or other as you are aware testing for covid in march was restricted to nhs workers and was not widely available i was also hospitalized in march three separate times and diagnosed with costochondritis and all other weird things. since leaving hospital in mid may i have deteriorated in strength to the point where walking and lifting things is almost impossible i have taken further steroids which has resolved bladder issues and numbness but the weakness and vision issue persists. i truly believe that my ms was activated by covid 19 and have recently had a second opinion by a specialist neuro who also finds it a very interesting case. i have never suffered any health issues in my past neurologically the only ailment i have is GI issues. I know you cannot give advice on specific cases but what would your opinion be if this case presented to you ? 7 lesions on brain and one in cervial spine positive igg bands localised csf.

  • Some people will have to suffer vaccine induced TM/MS for the common good? Would you still have this view if it happened to you or your family?

    • Yes, but it will depend on how common the adverse event is. Let’s assume it is a rare event in a similar ballpark to the yellow fever vaccine. If everyone wanted to avoid say a 1 in a 100,000 or 1 in a 1,000,000 adverse vaccine event we would not get herd immunity. I would go so far as to say that not getting vaccinated by piggy-backing or free-loading on the rest of society’s herd immunity is selfish. This is what the anti-VAXX movement is doing; however, they have been so good at convincing the population that vaccines are dangerous and bad for you that herd immunity is not being achieved with many of our childhood vaccines. Hence we are witnessing outbreaks of preventable infectious diseases such as measles and mumps, with deaths and severe complications. Very sad.

    • As a corollary how would you feel if one of your family members died of COVID-19 after they turned down an effective vaccine for SARS-CoV-2? I assume you wouldn’t have a problem with their death provided they had made an informed decision.

      How would you feel if a family member committed suicide? I assume you wouldn’t have a problem with this either provided they were of a sound mind.

      How would you feel if one of your elderly family members died of COVID-19 after they contracted the infection from your neighbour’s child who was not vaccinated with an effective vaccine for SARS-CoV-2 because your neighbour was an anti-VAXXer? I assume you wouldn’t have a problem with their death because your neighbour has the right not to allow their children to be vaccinated.

      This is a liberal view of the world; the sanctity of the individual to control their own life and to make potentially selfish decisions. The problem with vaccination is that some of the choices you make have implications for those around you. Vaccination for the greater good of society, i.e. herd immunity, is were liberalism is challenged as a philosophy and is also at odds with our evolutionary past.

      • The problem here in the US is that if you are the unlucky one with the adverse reaction, good luck having the security of health care for the long run. It´s a high likelihood of financial ruin. Yes, I know that there is a fund for adverse vaccine reactions, but good luck qualifying and the time delay in applying and receiving will not cover the immediate care and won´t be enough for the long term care.

      • Wow. I am not even an anti-VAXXer, yet I find your posts so insulting, offensive, and beyond triggering. We aren’t unethical morons. You aren’t omniscient. And you don’t get to force anyone into a game of Russian roulette. You are just as capable of being wrong as the rest of us are.

        If the vaccine isn’t safe, pharma needs to go back to the drawing board. I believe the risk is likely higher than 1 in 100,000 given the 2 cases of TM that have been revealed from vaccine study participants (in less than 6 months). What if there are more TM/MS cases to develop at a slower rate over the coming years? What’s the expense to society then??? Do you own AstraZeneca stock or something?

        I could go on and on and on about the shortcomings of your statement/harsh judgment of “liberal” thinkers. But…I can’t believe I’m saying this. You’ve brought me to a lifetime low…I JUST CAN’T!

        And OMG…MS is just a little old adverse event. OMG. I just popped a new lesion.

        • There is currently no evidence that the vaccine caused either TM or MS (both patients may have received the control vaccine and even that may have had nothing to do with the TM//MS).
          It is also really important to remember that PWMS who are taking immune suppressing drugs are likely to rely on herd immunity from others getting vaccinated at least initially if the Oxford vaccine is the first successful vaccine (since it is live). So I guess the question becomes how would you feel if you caught the virus (and suffered long term side effects from it in addition to MS) from someone who could have had the vaccine but didn’t.

  • So if the Astra Zeneca vaccine becomes available for public rollout would you have caveats about people with MS having it? That seems to be problematic to me ..but I am not an expert

    • We don’t have enough data yet to make this call. Let’s wait for the trials to resume and be completed so we can see how efficacious they are.

  • ProfG are you aware of what the implications are of non-MS related TM for PwMS, especially those of us with quite a high spinal lesion load?

    Also does the high rate of TM in Covid and any implications for PwMS influence your view on to what extent we should be trying to avoid contracting Covid?

    Thanks.

    • RE; “Also does the high rate of TM in Covid…”

      We don’t really know the rate of TM; all we have are the case reports that seem high. But COVID-19 may have led to reporting bias, i.e. neurologists are more likely to report TM with COVID-19 that with other infections because of the novelty. I suspect the rate is actually quite low. We may get information from the MS registers about whether or not COVID-19 triggers relapses, and spinal cord relapses. At present all we have is one case of TM and one case of MS post-vaccine, which is far to small a number to draw any conclusions.

    • Rare – less than 1 in 10,000 according to the SmPC. TM is part of the encephalomyelitis spectrum.

      Adverse events

      The following adverse events were reported following commercial use of Inactivated Influenza Vaccine (Split Virion) BP. A causal relationship with Quadrivalent Influenza Vaccine (split virion, inactivated) has not been established.

      • Blood and lymphatic system disorders
      Transient thrombocytopenia (1), lymphadenopathy (1)

      • Nervous system disorders
      Paraesthesia (1), Guillain-Barré Syndrome (GBS), neuritis, neuralgia, convulsions, encephalomyelitis

      • Vascular disorders
      Vasculitis, such as Henoch-Schönlein purpura, with transient renal involvement in certain cases

  • I had TM in my C spine, I had paralysis of both arms, during a severe ear infection. It was my first MS relapse and I had/have a full TM lesion in my C spine.
    Yes it did confuse a neurology registrar at time, as I had double vision too.
    Anyway, arms and eye recovered now.

    • My TM caused by MS took around one year to improve 50%, at three years it improved to about 60% and at five years it was about 90% recovered. It took a lot of self initiated rehabilitation, which I maintain daily.

    • No. I am saying let’s cross that bridge when it arrives. We need to see the data. However, it should be up to the individual to decide whether or not they want the vaccine or not. We live in a liberal democracy; hence, we can’t force people to be vaccinated.

  • I have TM and I wouldn’t wish it on anyone, I think saying that some people with have to suffer harm to protect the many or the herd Is,PLAIN MAD I suffer everyday with pain and tiredness and I think sciences did to know the damage things can do before the start injecting stuff into people

    • Unfortunately, no vaccine is safe. It is impossible to make a vaccine that has no potential severe adverse events. That is why it is so important to do large vaccine trials; they are large for safety reasons. This is why the wider community is so shocked by the Russian government’s approval of a coronavirus vaccine without adequate safety studies.

    • The same dilemma happens with most medical treatments. For example, we offer pwMS treatment with HSCT knowing that the mortality rate from the procedure is about 0.5%. In other words, 1 in 200 people will die from the procedure, but on the other side of the coin, the 199 out of 200 treated pwMS may benefit greatly from the treatment.

  • Thanks for your very comprehensive reply to questions asked re difference between CIS/MS TM [ie lesion(s) on cord] and post viral/vaccine TM.

    Sounds like there are lots of clues…. but love this:

    ‘This is why medicine and neurology remain as much an art as a science.’

    Out of interest, how long does post viral/vaccine TM typically take to resolve? And are there any long-term effects?

    • It all depends on how severe it is. Some people may not recover back to normal and are left with a disability. But it takes weeks to months to recover function back to being independent.

  • If infections can trigger MS relapses, would the post viral TM relapse in a pwMS be classed as post viral TM, or TM caused by MS but triggered by an infection?
    I guess looking at the length of the TM lesion is key, on the MRI scan, as you mention?

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