Post-acute Corticospinal and Spinal Tractopathy after Coronavirus Disease 2019: A Novel Post-infectious Neurological Syndrome?

We herein report two cases of tractopathy affecting the bilateral corticospinal tracts (CSTs) and the spinal cord following coronavirus disease 2019. Both patients developed progressive sensorimotor deficits with spasticity, a truncal sensory level with severely impaired deep sensation, and bowel/bladder dysfunction one to three months post-infection. Magnetic resonance imaging (MRI) revealed bilateral CST and lateral column lesions. Somatosensory evoked potentials confirmed posterior column dysfunction. Initial treatment with intravenous methylprednisolone and immunoglobulin was ineffective; however, multiple courses of immunotherapy and prolonged corticosteroids led to marked improvement. These cases suggest a tract-specific, delayed, immune-mediated process triggered by severe acute respiratory syndrome coronavirus 2, underscoring the need for extended immunotherapy for optimal recovery.