Late Recurrence of Neuromyelitis Optica Spectrum Disorder Following Multiple COVID-19 Vaccinations After Nearly Four Decades of Clinical Stability: A Case Report
This case report describes a 75-year-old woman with Neuromyelitis Optica Spectrum Disorder who experienced a rare disease recurrence nearly 40 years after her initial diagnosis following multiple COVID-19 vaccinations, highlighting the need for further investigation into potential vaccine-related immunologic triggers and the management of refractory spasticity.
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The human immune system is a vigilant guardian, designed to recognize and neutralize threats like viruses and bacteria. However, in a rare condition called Neuromyelitis Optica Spectrum Disorder, this defense system turns inward, mistakenly attacking the central nervous system. Specifically, it targets the optic nerves that carry visual signals to the brain and the spinal cord, which acts as the main highway for messages between the brain and the rest of the body. When these structures are inflamed, the result can be sudden vision loss, paralysis, and severe muscle stiffness. While the disease is known for recurring attacks, it is exceptionally rare for a patient to remain completely free of symptoms for decades before the disease suddenly wakes up again. Understanding what might trigger such a late return is crucial for doctors and patients alike, as it helps distinguish between natural disease progression and potential external causes.
This case report tells the story of a seventy-five-year-old woman who lived with this condition for over forty years without a single relapse. She was first diagnosed in 1982 at the age of thirty-one, after suffering a headache followed quickly by vision loss and paralysis below her torso. With the help of physical therapy and medication, she recovered most of her function and remained clinically stable from 1983 until 2020. For nearly four decades, her condition was quiet. Then, in 2021, she received multiple doses of the Moderna COVID-19 vaccine. Following these vaccinations, she began to experience a slow but steady decline. Her peripheral vision started to fade, her legs became increasingly stiff and difficult to control, and she suffered from nausea that could not be stopped by standard medication. She also experienced a stroke in July 2022, which complicated the picture, but the timing of her worsening symptoms closely followed her series of vaccine doses.
Doctors confirmed that her original disease had returned. They treated her with powerful intravenous steroids and a procedure called plasma exchange, which filters the blood to remove harmful antibodies. Despite these aggressive treatments, her leg stiffness, known medically as spasticity, remained severe and resistant to standard drugs. Her previous medication, which had worked well for years, no longer helped and seemed to make the stiffness worse. Other common treatments for nerve pain and muscle control provided only partial relief or none at all. As her mobility continued to deteriorate, her doctors turned to a different approach: injections of botulinum toxin, a substance often used to relax overactive muscles.
Starting in January 2025, she received a series of these injections into the large muscles of her thighs. The doctors carefully increased the dosage over several cycles, aiming to reduce the tension in her legs. For a short time, the injections offered some relief, allowing her muscles to relax for a few weeks. However, the improvement was temporary and did not lead to a lasting return of her ability to walk. In April 2026, the treatment was switched to a different type of botulinum toxin, and the injections were expanded to include more muscles in her legs and calves. This time, the treatment caused weakness in her legs rather than just relaxation. Ultimately, while the injections provided brief moments of symptom reduction, they failed to restore her function or offer a long-term solution.
The authors of this report emphasize that they cannot prove the vaccines caused her relapse. It is possible that her disease returned on its own, or that her stroke played a major role in her decline. The original diagnosis was made before modern blood tests were available, and a test for the specific antibody associated with this disease came back negative when she relapsed, leaving some uncertainty about the exact nature of her condition. However, the timing of her symptoms appearing after repeated vaccinations, combined with other reports of similar events, suggests that the immune system's activation from the vaccines might have played a part in waking up her dormant disease. This case serves as a reminder that while vaccines are vital, they can occasionally be associated with unexpected immune responses in people with a history of autoimmune disorders.
The story also highlights the difficulty of managing severe muscle stiffness when standard medicines fail. The patient's experience with botulinum toxin showed that while it can temporarily relax muscles, it is not a cure-all, especially when the underlying nerve damage is complex and long-standing. The treatment provided only fleeting benefits and eventually led to weakness, illustrating the delicate balance doctors must strike when treating such refractory symptoms. This case adds a new chapter to the medical understanding of how long-term stability in autoimmune diseases can be disrupted and underscores the need for more research into what triggers these late recurrences and how best to treat the stubborn symptoms that follow.
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