Neurologic complications of COVID-19 are well-described; however, myelopathies associated with COVID-19 are comparatively rarer events. Myelopathies associated with vaccination are even rarer than those seen with infection. There is a need to recognize and document these rare cases as the number of infections and vaccinations increase to refine diagnosis and treatment.

We reviewed the clinical profiles of 15 patients referred to the Johns Hopkins Myelitis & Myelopathy Center between April 2020 and June 2022 for myelopathic syndromes suspected to be triggered by SARS-CoV-2 infection or COVID-19 vaccination. Each patient’s etiology was classified as vascular, inflammatory, unmasking of neurological disease, or unknown.

All vascular myelopathies (n=5) were associated with COVID-19 and presented as acute and subacute progressive bladder dysfunction and weakness with non-enhancing lesions on MRI. Inflammatory myelopathies were associated with vaccination (n=3) and COVID-19 (n=2) and were notable for CSF pleocytosis, elevated protein, and involvement of white matter tracts and grey matter on MRI. COVID-19 and vaccination were associated with unmasking underlying myelopathic disease (e.g., demyelinating or metabolic) in 4 patients. Among the vaccination group (n=5), 2 received one dose of the mRNA-1273 vaccine and 3 received one dose of the Ad26.COV2.S vaccine. One patient could not be classified. 

Initial imaging in vascular patients had subtle findings recognized in hindsight– early recognition on imaging could refine differential diagnosis. Patients with inflammatory etiologies generally only saw improvement in their symptoms after PLEX; early initiation can halt progression and improve outcomes. Among the unmasked group, patients had heterogeneous clinical presentations. Imaging in this group showed chronic lesions, unlike the other two groups. It is critical to identify the etiological factors in subjects with myelopathies in the setting of COVID-19 or vaccination to establish an appropriate treatment.