Dr. Salazar presents a case of transverse myelitis in a complex patient transferred from the ICU.
Teaching points:
1. What are some physical exam findings consistent with disorders of the spinal cord/myelopathies?
Presenting signs and symptoms often occur at or below the site of the lesion
Injury to the corticospinal tracts --> spastic paresis or paralysis, weakness, hyperreflexia, muscle spasms and extensor plantar reflexes
More distal involvement (lower roots/cauda equina syndrome) --> weakness of lower motoneuron type with decreased tone and areflexia
Usually has a distinct sensory level
Gait is abnormal - subtle spastic gait or sensory ataxia to complete paralysis
Most patients will have pain at the level of compressive disease, with focal tenderness to palpation over spinal column
May describe squeezing or banding sensations around the chest or abdomen - may lead to cardiac, pulm, or GI evaluations
Disruptions in bowel and bladder function
2. What is transverse myelitis?
Monophasic, inflammatory, and demyelinating disorder of the spinal cord (affecting both grey and white mater)
Affects one region of the spinal cord
Considered to be para-or post-infectious, but should rule out or consider infectious causes (HSV, VZV, west nile virus, human T-lymphotropic virus, lyme, neurosyphilis, HIV)
HIV can cause a transverse myelitis-like syndrome at the time of seroconversion or result in chronic degenerative vacuolar myelopathy in patients with low CD4
MTB can infect meninges and spinal cord and present with transverse myelitis-like syndrome
Subacute weakness, sensory changes, bladder or bowel dysfunction
Diagnostic criteria: clinical features + evidence of inflammation (CSF leukocytosis or enhancement on spinal cord) + exclusion of other potential causes
3. How is this different from MS?
It may be a spectrum of disease including ADEM, MS, NMO, AFM
ITM is more likely to have lack of elevated oligoclonal bands or IgG index in CSF
Unlikely to have brain lesions on MRI
4. Management of ITM?
Evaluate/rule out infection
IV methylprednisoline 1g/d for 3-7 days
If refractory to glucocorticoids, may benefit from plasmapheresis or cyclophosphamide
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