This case report describes a longitudinally-extensive transverse myelitis after Moderna SARS-CoV-2 vaccination.

Transverse myelitis (TM) is an inflammatory spinal cord syndrome presenting with acute-to-subacute neurological deficits. A lesion spanning three or more vertebral segments on imaging is considered "longitudinally-extensive." The TM differential is broad--among these etiologies, vaccination is a rare but recognized entity.

60-year-old, right-handed man with chronic right hemisphere stroke with residual left hemiparesis admitted for four days of bilateral lower extremity numbness progressing to weakness and urinary and bowel incontinence 10 days after receiving his second Moderna SARS-CoV-2 vaccination. Examination showed hypotonic lower extremities, proximal greater than distal weakness, a T9 dermatome sensory level, perineal numbness, mildly-reduced rectal tone, and preserved reflexes. MRI spine revealed a longitudinally-extensive, non-enhancing T2-hyperintense lesion spanning T8-T12. CSF analysis demonstrated 5 white blood cells, 1271 red blood cells, 124 glucose, and 55 protein. Aside from mildly elevated ESR and CRP, extensive serum and CSF work-up for other causes of myelopathy, including nutritional/toxic (copper, zinc, heavy metals), infectious (RPR/VDRL, HIV, HTLV, HSV, VZV, West Nile), and rheumatologic (anti-Jo, anti-Mi-2, anti-Ro/La, anti-smith, anti-Scleroderma, anti-dsDNA, anti-ribosomal P, anti-RNP), were unremarkable. Anti-NMO and anti-MOG antibodies were negative. He improved with methylprednisolone 1000 mg daily for five days suggesting an autoimmune etiology.

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Transverse myelitis has a broad presentation and differential, requiring detailed history-taking to determine the cause as management differs between etiologies. SARS-CoV-2 and post-vaccination are known etiologies for TM. Given the timing of our patient’s symptom onset after vaccination and thorough exclusion of other causes, we postulate a potentially novel case of TM associated with the Moderna SARS-CoV-2 vaccine. Though post-vaccination myelopathy is potentially debilitating if untreated, it is rare, and the benefits of vaccination appear to outweigh the risks.