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Updated: Jun 12 2019

Transverse Myelitis

  • 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
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