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But what about the weakness??

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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