Snapshot A 37-year-old male presents with lower extremity numbness, weakness, and sexual dysfunction. His symptoms began 2 days prior, and has progressively worsened. Medical history is significant for pneumonia caused by Mycoplasma pneumoniae. He denies weight loss, night sweats, or recent vaccinations. Physical exam is notable for bilateral lower extremity sensory deficits and motor weakness. Both bulbocavernous and anal wink reflex are absent. MRI of the brain and spine are performed. There is no intracranial pathology. There is a gadolinium enhancing lesion on greater than two spinal cord levels in the lumbar spine. A lumbar puncture is performed, which shows cerebrospinal fluid pleocytosis, and an increased IgG index. Introduction Neuro-inflammary disease of the spinal cord can lead to muscle weakness sensory alterations autonomic dysfunction There is pathologic heterogeneity can be primary (e.g., idiopathic) or secondary (e.g., systemic autoimmune disease) Can have a partial or complete effect on the spinal cord Epidemiology Affects any age Bimodal distribution ~10 - 19 years and 30 - 39 years Predilection depends on the underlying etiology of the lesion Etiology Post-infectious bacteria Mycoplasma pneumoniae Campylobacter jejuni virus hepatitis A, B, C MMR EBV influenza Post-vaccination Demyelinating disease multiple sclerosis neuromyelitis optica demylinating encephalomyelitis Systemic autoimmune disease systemic lupus erythematosus Sjögren's syndrome Behçet's disease ankylosing spondylitis Medications sulfasalazine TNF-α inhibitors Presentation Symptoms - acute or subacute development sensory alterations weakness autonomic dysfunction e.g., bowel and bladder incontinence, sexual dysfunction Physical exam identifies a sensory level if complete transverse myelitis symmetrical/complete motor, sensory, and autonomic abnormalities if partial transverse myelitis asymmetric/partial motor, sensory, and autonomic abnormalities Evaluation Must rule-out other causes of spinal cord compression diagnosis requires signs and symptoms of motor, sensory, and autonomic abnormalities in certain spinal cord levels in the absence of compression as well as signs of inflammation MRI necessary to evaluate for structural or compressive pathologies preferred imaging modality with and without gadolinium for brain with gadolinium for spine CT spine or myelogram can be used as an alternative when MRI is not available Lumbar puncture CSF pleocytosis ↑ IgG index Blood tests to rule out other causes e.g., anti-aquaporin-4 IgG (NMO-IgG), vitamin B12 level, methylmalonic acid, HIV antibodies Differential Spinal cord compressive lesion malignancy Nutritional deficiency vitamin B12, E, D, copper Vascular causes infarction of the anterior spinal artery AV fistula Radiation myelitis Treatment High dose corticosteroids first-line Plasma exchange in those who are unresponsive to corticosteroids