Acute inflammatory Transverse Myelitis post Pfizer-BioNTech-COVID-19 vaccine in 16-year-old

Coronavirus disease 2019 (COVID-19) originated in China in early March 2019. Saudi Food and Drug Authority approved the registration of the Pfizer-BioNTech COVID-19 vaccine in Saudi Arabia on December 10, 2020 and on May 10, 2021, Pfizer-BioNTech was given an authorized emergency use in 12 to 15 years old children. Saudi Arabia’s Ministry of Health started Pfizer-BioNTech COVID-19 vaccination for 12 to 18 years old on June 27, 2021. Here we have a case of 16-year-old female admitted to the medical ward diagnosed with acute inflammatory transverse myelitis after two weeks from second dose of the Pfizer-BioNTech COVID-19 vaccine. The diagnosis was based on normal laboratory workup but significant radiological findings. She was discharged after a full recovery. There are multiple cases of post-vaccine acute inflammatory transverse myelitis shared by medical journals, but due to lack of literature review for the teenager population, we think our case may be the first case of acute inflammatory transverse myelitis following second dose of Pfizer-BioNTech COVID-19 vaccine in this population.


Introduction
Coronavirus disease 2019 (COVID-19) has claimed deaths of many people since its outbreak and declaration by WHO as a pandemic. Several research institutions and companies have made substantial efforts to develop COVID-19 vaccines [1]. Upon approval by the regulatory agencies Reporting System (FAERS) as of March 2, 2021, include neurological symptoms such as paresthesia, muscle spasm, headache, myalgia, pain, and dizziness [4]. Rare cases of transverse myelitis, stroke, acute disseminated encephalomyelitis, facial palsy, tinnitus, tremor, seizure, dysphonia, and diplopia have also been reported in the literature.
Transverse myelitis is a medical condition emanating from spinal cord inflammation, which is a characteristic of neurological dysfunction of the sensory and motor tracts located on both sides of the spinal cord. Studies report transverse myelitis as a complication due to COVID-19 infection. Several case reports have linked neurological complications such as transverse myelitis to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection [5][6][7][8][9][10][11]. The clinical cases involved both males and females, aged between 28 and 63 years. The tests conducted initially confirmed that the patients were SARS-CoV-2 positive. Blood analysis indicated leukopenia in addition to a slightly higher level of C-reactive protein (CRP). Spine MRI showed hyperdensity, especially in the transverse region.
The lumbar puncture results and blood neutropenia conclusively suggest viral pathogen as the causative agent [7].

Case Presentation
A 16-year-old female, otherwise healthy, presented to the emergency department of the hospital with lower extremity weakness and difficulty in walking for three days. Detailed medical history revealed that the patient was administered a second dose of Pfizer-BioNTech-COVID-19 vaccine on July 26, 2021, and two days after the administration, the patient noticed weakness in her lower extremity. As the days went by the weakness gradually progressed to her upper extremity with numbness of both the lower limbs; and finally on August 11, 2021, the patient sought medical care.
There was no history of being febrile before vaccination; no bowel or bladder dysfunction, headache, seizure, or loss of consciousness was reported. A physical examination was conducted to show that her temperature was 37 degrees Celsius, her blood pressure was 110/65 mmHg with a heart rate of 85 beats per minute, and 100% oxygen saturation with a respiratory rate of 18 breaths per minute.
The neurological examination was unremarkable except for a moderate decline in the power of all extremities, decrease sensation to fine and pain stimuli in the lower extremity, increased tone with spasticity pattern, and hyperreflexia with present Babinski sign. Cranial nerves and cerebellum examination were unremarkable.  Table 1 Results for the magnetic resonance imaging (MRI) implied an acute inflammation on the spine as shown by the dorsal spinal cord, including contrast of the cervical (Figure 1), and thoracic ( Figure 2) spinal cord, with normal MRI of the brain (Figure 3).

Discussion
Transverse myelitis is a disorder characterized by the spinal cord focal inflammation that Sjögren's syndrome that injures the spinal cord. Although many cases of transverse myelitis are correctly diagnosed, the actual causes for 30% of the cases are not known [18].
Vaccines have also been reported as a potential cause of transverse myelitis [19,20]. Other case reports involving transverse myelitis due to administration of COVID-19 vaccines exhibit almost similar symptoms and results [21][22][23][24][25]. Malhotra et al. reported their first case of transverse myelitis as an adverse event following the administration of AstraZeneca/Oxford (viral-vectored, recombinant ChAdOX1) COVID-19 vaccine [24]. The patient who registered abnormal sensations on the lower limbs received the AZD1222 (ChAdOx1) vaccine eight days ago. Results for the MRI of the spine revealed "an ovoid T2-hyperintense lesion in the dorsal aspect of the spinal cord at C6 and C7 vertebral levels" which signaled demyelination as a result of vaccination [24].
Fitzsimmons and Nance also reported a case of transverse myelitis due to the Moderna vaccine [25]. The patient reported increasing lower back pain along with pain and numbness in the calves of both legs, which extended to the ankle. Laboratory tests and MRI of the lumbar and cervical regions of the spine revealed an increased T2 cord signal in the distal spinal cord and conus, suggestive of transverse myelitis due to vaccination [25].

Conclusion
Our 16-year-old patient was diagnosed with transverse myelitis that appeared after two days of administering the second dose of Pfizer-BioNTech COVID-19 vaccine and required hospitalization and management for five days. We publish our case for health administration to take notice of the possibility of serious adverse effects in the teenager population.

Additional Information:
Ethic approval and consent to participate: Institutional Review Board-Makkah approved research conduct at Sep/10/2021 with reference number Human Subject: consent was obtained verbally and written from the parent of the patient -as the patient is underage of 18-years-old -. Funding: no funding was needed/received. Availability of data and materials: the submitting primary author has the research data. Conflict of interest: with the completed form of International Committee of Medical Journal Editors (ICMJE), the authors declare no financial support given or having a relationship with any organization may benefit from this article. Authors' contributions: study conception, AA and GB; review and editing, AA, GB, and AK; data collection and extraction, AS; supervision, AK, and GB; treating medical team; AK.