(Kiosk 3) Transverse Myelitis Associated with Monkeypox: A Case Report

Case Diagnosis: 36-year-old male with monkeypox-associated transverse myelitis

Case Description or Program Description: A 36 year old male with a history of HIV was diagnosed with monkeypox and started tecovirimat. He was admitted 3 days later for acute onset of left upper quadrant and flank pain, paraspinal tenderness, and bilateral lower extremities numbness. He required catheterization for inability to void. After 12 hours from admission, he started having ascending legs weakness L>R.

The MRI spine showed extensive signal abnormality within the cord from T1 to the T9-T10 level, no contrast enhancement. MRI brain showed non-enhancing T2/FLAIR hyperintensities within the left external capsule, right middle cerebellar peduncle and left cerebellar white matter. Lumbar puncture with 883 WBC, protein 241, glucose 48. Meningitis/encephalitis panel negative. HIV RNA and viral load not detected. He received 1g Methylprednisone x 3 doses, followed by 5 sessions of IVIG with no improvement. He ultimately had PLEX for 5 sessions.

On admission to inpatient rehabilitation, he had normal upper extremity strength (5/5), lower extremity flaccid paralysis (0/5) with absent clonus and reflexes, and diminished/absent sensation below T4.

He underwent successful rehabilitation and by the time of discharge home was independent in self-care and mobility. On discharge he remained T4 complete paraplegia (AIS A). He continues to be followed as an outpatient and since discharge has improved in motor and sensory function.

Setting: Tertiary care hospital and outpatient rehab

Assessment/Results: After 3 months of outpatient rehab including FES the patient remains with T4 paraplegia (AIS A) but has progressed to a motor zone of partial preservation to S1

Discussion (relevance): This is the first reported case, to our knowledge, of monkeypox associated transverse myelitis. Rehabilitation maximized his functional outcomes.

Conclusions: Transverse myelitis can be a complication of Monkeypox infection, with viral neuro-invasiveness being a particular concern in immunocompromised individuals.