Comparison between MRI-negative and positive results and the predictors for a poor prognosis in patients with idiopathic acute transverse myelitis.

BACKGROUND: Idiopathic acute transverse myelitis (IATM) is a focal inflammatory disorder of the spinal cord that results in motor, sensory, and autonomic dysfunction. However, the comparative analysis of MRI-negative and MRI-positive in IATM patients were rarely reported. OBJECTIVES: The purpose of this study was to compare MRI-negative with MRI-positive groups in IATM patients, analyze the predictors for a poor prognosis, thus explore the relationship between MRI-negative and prognosis. METHODS: We selected 132 patients with first-attack IATM at the First Affiliated Hospital of Nanchang University from May 2018 to May 2022. Patients were divided into MRI-positive and MRI-negative group according to whether there were responsible spinal MRI lesions, and good prognosis and poor prognosis based on whether the EDSS score ≥ 4 at follow-up. The predictive factors of poor prognosis in IATM patients was analyzed by logistic regression models. RESULTS: Of the 132 patients, 107 first-attack patients who fulfilled the criteria for IATM were included in the study. We showed that 43 (40%) patients had a negative spinal cord MRI, while 27 (25%) patients were identified as having a poor prognosis (EDSS score at follow-up ≥ 4). Compared with MRI-negative patients, the MRI-positive group was more likely to have back/neck pain, spinal cord shock and poor prognosis, and the EDSS score at follow-up was higher. We also identified three risk factors for a poor outcome: absence of second-line therapies, high EDSS score at nadir and a positive MRI result. CONCLUSIONS: Compared with MRI-negative group, MRI-positive patients were more likely to have back/neck pain, spinal cord shock and poor prognosis, with a higher EDSS score at follow-up. The absence of second-line therapies, high EDSS score at nadir, and a positive MRI were risk factors for poor outcomes in patients with first-attack IATM. MRI-negative patients may have better prognosis, an active second-line immunotherapy for IATM patients may improve clinical outcome.

A Tale of Two Afflictions: Transverse Myelitis and COVID-19 in a Young Female Patient.

Acute transverse myelitis (ATM) is a syndrome of multiple etiologies, with acute or subacute onset in which inflammation of the spinal cord results in neurological deficits, including weakness, sensory loss, and autonomic dysfunction. It is often associated with infectious or autoimmune etiologies but can be considered idiopathic when extensive workup is negative. We present a case of a young African American female who presented with acute onset of bilateral lower extremity weakness, loss of sensation, and autonomic dysfunction. On physical exam, she had absent lower extremity reflexes, 0-1/5 power, and markedly diminished sensation with no pain/temperature discrimination with an abdominal sensory level at T4. There was no upper extremity involvement. She was incidentally found to be COVID-19-positive and denied ever being vaccinated in the past. MRI of the spine revealed diffuse signal abnormality within the cervical and thoracic spine extending to the conus, and an MRI of the brain showed two white matter lesions in the frontal lobes. Lumbar puncture showed lymphocytic pleocytosis and elevated protein; Gram stain did not reveal any pathogen. The patient was treated initially with high doses of steroids with minimal response. She underwent multiple sessions of plasmapheresis with good tolerance and response. Differential diagnoses considered for this case were Guillain Barre syndrome, neuromyelitis optica (NMO), multiple sclerosis, SLE-induced transverse myelitis, or infectious cases. All lab work and workup came back negative for these diseases, leaving us with an interesting culprit: COVID-19 associated. There have been few cases mentioned in the literature of transverse myelitis caused by COVID-19, and this remains a possibility, as all other causes were ruled out.

Rehabilitation of Rare Neurological Complications of COVID-19 Infection in Health Resort Settings.

There is increasing evidence of neurological involvement in patients with coronavirus disease. Reports of neurological manifestations include altered mental status, Guillain-Barré syndrome (GBS) and its forms, encephalopathy, psychosis, neurocognitive (dementia) syndrome, ischemic strokes, intracerebral hemorrhage, and acute transverse myelitis. We present three patients with rare neurological manifestations of the COVID-19 disease, with a special focus on rehabilitation in a health resort setting. Outcomes were evaluated based on neurological examination and the modified Barthel index. We highlight the importance of an interdisciplinary approach to reduce disability and improve functionality and quality of life.

Acute Transverse Myelitis as an Unusual Complication of Dengue Fever: A Case Report and Literature Review.

Dengue fever, the most prevalent arbovirus disease, has a broad spectrum of clinical manifestations, ranging from asymptomatic to dengue hemorrhagic fever and dengue shock syndrome. Dengue fever has the potential to involve the nervous system. Acute transverse myelitis is a life-threatening complication of dengue fever, though rarely reported. We report a case of dengue fever-induced transverse myelitis in a 51-year-old male who presented with progressive paraplegia, sensory disturbance, and urinary retention preceded by a febrile illness, vomiting, and retro-orbital pain two weeks before. His serology was positive for immunoglobulin M (IgM) to dengue virus and non-structural protein (NS-1). Magnetic resonance imaging revealed hyperintense signals suggestive of acute transverse myelitis. After ruling out all other possible causes, a possible diagnosis of dengue fever-induced transverse myelitis was made. His condition improved gradually after starting methylprednisolone.

Functional Recovery and Regenerative Effects of Direct Transcutaneous Electrical Nerve Stimulation in Treatment of Post-COVID-19 Guillain-Barré and Acute Transverse Myelitis Overlap Syndrome: A Clinical Case.

Transcutaneous electrical nerve stimulation (TENS) has proven effective in treating pain in many experimental and clinical studies. In addition to the analgesic effect, direct TENS of peripheral nerves had anti-inflammatory and regenerative effects in the treatment of distal polyneuropathy and spinal cord injury. This work demonstrates the experience of using direct TENS in the treatment of a 52-year-old patient with post-COVID-19 Guillain-Barré (GBS) and acute transverse myelitis (ATM) overlap syndrome. Direct TENS of peripheral nerves showed high efficiency in enhancing the therapeutic effect of combined plasma exchange and pharmacotherapy by 89.5% with a significant reduction in neuropathic pain, motor and sensory deficits, bladder and bowel disorders and regression of neurophysiological changes. We suggest that direct TENS of peripheral nerves can be a promising option for combined therapy of GBS and ATM overlap syndrome and other diseases with the simultaneous development of distal polyneuropathy and spinal cord injury. Further trial studies are required.

Postpartum Hypocupric Myelopathy Masquerading as Acute Transverse Myelitis: A Case Report and Literature Review of a Rare Presentation.

The symptoms of transverse myelitis, an acute demyelinating inflammatory condition of the spinal cord, include motor, sensory, and bowel-bladder dysfunction that can develop suddenly or gradually. Several etiologies, such as bacterial, fungal, or viral infections, cancer, autoimmune diseases, vascular problems, and environmental variables, can cause it. The identification of copper deficiency myelopathy (CDM) as a curable cause of non-compressive inflammatory myelopathy has only occurred recently. Patients frequently present with sensory complaints and a spastic gait. The neurological disease may exist independently of the hematologic signs. Only a few cases of copper myelopathy in peripartum women have been documented. Given that hypocupric myelopathy is a treatable cause of debilitating paraplegia, maintaining clinical vigilance will be crucial in minimizing neurological sequelae, as demonstrated in this case report.

Coexistence of longitudinally extensive transverse myelitis and diffuse midline glioma in the brainstem in an adolescent boy with acute flaccid paralysis.

We present the case of a previously healthy 13-year-old boy who was admitted to the emergency department with acute flaccid paralysis. Magnetic resonance imaging revealed radiological evidence of longitudinally extensive transverse myelitis. Additionally, homogeneous T2 signal increase was observed in the pons and medulla oblongata, initially indicating brainstem encephalitis. Subsequent evaluations confirmed a coexistence of diffuse midline glioma (DMG) in the brain stem alongside acute transverse myelitis (ATM). Children with ATM generally have a more favorable prognosis than adults. However, despite the implementation of advanced treatment methods, the patient's quadriplegia did not improve and resulted in spinal cord sequela atrophy. DMG exhibits an aggressive growth pattern and lacks a known curative treatment. This case represents an exceedingly rare synchronous occurrence of aggressive conditions, underscoring the importance of raising awareness among physicians. Furthermore, we aim to discuss the radiologic differential diagnosis, as this is the first documented instance in the literature.

Electroacupuncture for acute transverse myelitis following viral infection: A case report.

BACKGROUND: Electroacupuncture (EA) has a positive effect on neurological repair and functional recovery following spinal cord disease. However, evidence of its effectiveness in acute transverse myelitis (ATM) cases is limited. PATIENT PRESENTATION: A 48-year-old woman experienced headache and fever for 5 days, followed by a sudden onset of back pain, lower limb paralysis, and urinary and bowel dysfunction. The patient received intravenous medications. However, she did not experience improvement in clinical symptoms. She subsequently underwent acupuncture treatment. She regained walking ability and experienced improved bladder function and bowel control after 36 sessions of EA treatment. METHODS: CARE guidelines informed the case study report. The MRC and ICIQ-UI-SF scores were used to verify changes in lower-extremity muscle strength and urination after EA treatment. Qualitative information was collected using feedback tables. CONCLUSION: Pharmacological treatment for ATM lacks clear advantages because of its complex pathophysiological mechanisms. Hence, EA could be recommended as a promising treatment modality for ATM.

A Case of Longitudinally Extensive Transverse Myelitis Following COVID-19 Infection.

One of the rare complications following acute COVID-19 infection is acute transverse myelitis (ATM). With only a few cases of ATM reported in the literature, an addition of longitudinally extensive transverse myelitis (LETM) diagnosed in our patient would underscore the complexity and diversity of neurological manifestations associated with this viral illness. A 54-year-old patient presented to the emergency department with fever, shortness of breath, nausea and vomiting. The patient's nasopharyngeal swab for COVID-19 polymerase chain reaction (PCR) resulted positive. Few days later, the patient developed bilateral upper, lower extremities weakness, back pain, urinary retention and dysphagia. Subsequently, the clinical presentation, MRI, cerebrospinal fluid (CSF) and laboratory findings pointed toward LETM as a complication of COVID-19 infection over other differentials. The aggressiveness of this disease necessitated high-dose steroids and plasmapheresis, pain control medication and rehabilitation which led to a slight improvement in the neurological symptoms at the time of discharge to the rehabilitation facility.

The value of 3D T2-weighted SPACE sequence in the differential diagnosis of spinal arteriovenous fistula and acute transverse myelitis.

OBJECTIVE: Spinal arteriovenous fistulas (SAVF) was often neglected and misdiagnosed as acute transverse myelitis (ATM) due to its insidious onset and non-specific clinical symptoms. This study aims to investigate the differential diagnostic value of high-resolution T2-weighted volumetric sequence (3D sampling perfection with application-optimized contrasts using different flip-angle evolutions [SPACE]) in patients with SAVF and ATM. METHODS: Retrospectively analyzed the clinical and radiological findings of 32 SDAVF patients and 32 ATM patients treated at our institutions from May 2018 to January 2023. They all underwent conventional spinal MRI and T2-SPACE examination, compared their performance in identifying lesions, to estimate the value of T2 SPACE sequence in the diagnosis of SAVF and ATM patients. RESULTS: The clue of cauda equina area change (CEAC) in conventional MRI and T2-SPACE sequences is specific for the diagnosis of SAVF. The diagnostic model composed of perimedullary flow voids (PFV) and CEAC has good diagnostic performance (AUCMRI = 0.95; AUCSPACE = 0.935). Compared with conventional MRI, the T2-SPACE sequence has a higher detection rate, sensitivity, and negative predictive value for PFV and CEAC in SAVF patients, but lower specificity and positive predictive value. In T2-SPACE images, there are significant differences in the distribution range, quadrant, and maximum diameter of PFV vessels between SAVF and ATM patients. Moreover, T2-SPACE sequence can determine the site of fistula in most SAVF patients preferably, and the inter-rater agreement was good in the assessment of the fistula. CONCLUSION: The CEAC is a new and useful clue for the diagnosis of thoracolumbar SAVF. And T2-SPACE sequence can more intuitively observe the lesions of SAVF, has good differential diagnostic value for SAVF and ATM patients.

An Observational Study of Multi-Faceted Demyelinating Disorders.

BACKGROUND AND OBJECTIVES: Idiopathic inflammatory demyelinating diseases of the central nervous system (IIDCDs) are wide-ranging disorders due to their similarities and differences. In order to address these conditions, studying their characteristics is essential. The endpoints of our study were to assess the incidence, presenting features, MRI findings, and predictors of disease progression of prevalent demyelinating disorders. MATERIAL AND METHODS: This prospective, observational study was conducted at Srirama Chandra Bhanja (SCB) Medical College and Hospital, India, from August 2018 to November 2021. Individuals of 18-65 years of age with common demyelinating disorders were assessed at baseline, six, 12, and 24 months. Univariate and multivariate analyses were performed for the assessment of predictors. We used R software (version 4.2.1; R Foundation for Statistical Computing, Vienna, Austria) for data analysis. RESULTS: Two hundred twenty (79%) of 278 enrolled participants completed this study. The mean age of the study population was 52.3±11.4 years. One hundred thirty-eight (63%) of them were males. The most common IIDCD in our study was neuromyelitis optica spectrum disorder (NMOSD: 87, 39.5%), followed by multiple sclerosis (MS: 72, 32.7%), acute transverse myelitis (ATM: 35, 15.9%), and acute disseminated encephalomyelitis (ADEM: 26, 11.8%). The univariate analysis revealed that male gender, diabetes mellitus, and history of smoking or alcoholism were significant predictors of the disease progression. CONCLUSION: The IIDCDs were polysymptomatic at the initial presentation. Male diabetics are more prone to progressive disorders. However, multivariate analysis did not provide statistically significant results.

Clinical presentation of the first demyelinating event in pediatrics / [Presentación clínica de primer evento desmielinizante en pediatría.]

Introduction: Isolated Clinical Syndrome (ACS) refers to the first clinical event with characteristics suggestive of multiple sclerosis (MS). Clinical case: We report the case of a previously healthy 8-year-old male patient hospitalized for altered gait with suspicion of transverse myelitis. Spinal MRI was performed showing evidence of hyperintense D3-D5 lesion in T2. He receives treatment with intravenous corticosteroid therapy and with the result of oligoclonal bands in serum and CSF, a diagnosis of ACS is made. Conclusion: The objective is to describe a rare form of manifestation of demyelinating disease in pediatric age and to assess the importance of timely diagnosis and treatment.

Introducción: El síndrome Clínico Aislado (SCA) hace referencia al primer evento clínico con características sugestivas de esclerosis múltiple (EM). Caso clínico: Se comunica el caso de un paciente masculino de 8 años previamente sano internado por alteración de la marcha con sospecha de mielitis transversa. Se realiza RMN medular donde se evidencia lesión en D3-D5 hiperintensa en T2. Recibe tratamiento con corticoterapia endovenosa y con resultado de bandas oligoclonales en suero y LCR se realiza diagnóstico de SCA. Conclusión: El objetivo es describir una forma poco frecuente de manifestación de enfermedad desmielinizante en la edad pediátrica y valorar la importancia del diagnóstico y tratamiento oportuno.

Bagel sign in neuro Behçet's disease myelitis: neuroimages.

Neuro-Behçet's disease (NBD) is a chronic heterogenous autoimmune disorder. It may involve central or pripheral nervous system but rarely shows spinal cord involvement (SCI). Bagel Sign is a unique sign of SCI due to NBD. It is a central T2W hyperintense lesion with a hypointense core on axial magnetic resonance imaging (MRI). This sign may be a complete or an incomplete ring with or without post-contrast enhancement. Here we report a patient with NBD whose primary presentaion was transverse myelitis. A 14-year-old patient was admitted due to triparesis and urinary retention. He had T2W hyperintensities from the left basal ganglion down to the T10 level. A similar anteromedial spot has been described in anterior spinal cord infarction which favors an ischemic pathogenesis for NBD. To our knowledge this is the first report of Bagel Sign and longitudinally extensive transverse myelitis with gray matter involvement.

Extensive longitudinal acute transverse myelitis complicated by pulseless ventricular tachycardia and recent shingles vaccination.

This case describes a 50-year-old male with a history of psoriatic arthritis who presented to the emergency department with a chief complaint of ascending bilateral lower extremity paresthesia one week following a shingles vaccine. MRI of the patient's spine was significant for longitudinally extensive T2 hyperintensity involving the lower cervical spine with extension into the upper thoracic spine suggestive of acute transverse myelitis (ATM). The patient's hospital course was complicated by a self-limiting episode of pulseless ventricular tachycardia accompanied by a brief loss of consciousness. Initial treatment included IV solumedrol, however due to lack of clinical improvement after a 5-day steroid treatment, plasmapheresis was initiated. The patient's condition improved with plasmapheresis and he was subsequently discharged to a rehab facility with a diagnosis of ATM of unclear etiology. Extensive serology, cardiac and CSF studies failed to determine the cause of this patient's myelitis or pulseless ventricular tachycardia. The following case report explores the potential factors that may have contributed to this patient's symptoms.

Sinus Node Dysfunction and Acute Transverse Myelitis As Initial Presentation of Systemic Lupus Erythematosus in a 55-Year-Old Female: A Case Report.

Systemic lupus erythematosus (SLE) is an autoimmune disease involving various organ systems. However, some of these lupus manifestations are underreported but life-threatening, so these unusual presentations need to be documented. This study aims to report a case of sinus node dysfunction (SND) and acute transverse myelitis (ATM) as the initial presentation of SLE. A 55-year-old Filipina newly diagnosed with SLE initially presented with progressive left upper extremity weakness and numbness within two days. On admission, the patient was noted to have 3/5 left upper extremity weakness and progressive C4-C6 dermatome paresthesia. A computed tomography scan of the brain was negative for infarction or hemorrhage. However, on magnetic resonance imaging of the spine, an ill-defined focus of enhancement was noted from C1 to C4 and extensive edema extending from C1 to mid-C6 vertebra. ATM was considered; hence high dose of intravenous methylprednisolone was given for five days with a notable improvement in motor and sensory deficits. Patients within the same admission also developed an onset of atrial fibrillation in rapid ventricular response in the background of baseline sinus bradycardia with associated episodes of fatigue. SND, attributed to SLE, persisted despite steroids. Pacemaker insertion was done as definitive management. The patient was discharged with the improvement of motor strength to 4+/5 and with prednisone and hydroxychloroquine as discharge medications. In conclusion, recognition and documentation of SLE's rare but life-threatening presentations, such as SLE-ATM and SND, are essential to facilitate timely therapeutic management.

Fampridine in multiple sclerosis patients with acute phase of cervical transverse myelitis: a double-blind, randomized placebo-controlled trial.

BACKGROUND: Fampridine is a potassium channel blocker drug used to improve walking ability in patients with multiple sclerosis (MS). We evaluated the effect of fampridine in patients with MS in the acute phase of transverse myelitis. METHODS: In a randomized, placebo-controlled trial, 30 patients who had their first episode of cervical myelitis with quadriparesis presentation, with the final diagnosis of MS, were randomly divided into two equal groups. The intervention group received intravenous methylprednisolone (IVMP) for 7 days plus fampridine. The placebo group received IVMP for 7 days plus placebo. To compare the treatment results, we compared the Barthel index (BI) scores of the groups at the start of the trial and the 21st day after the start of treatment. RESULTS: There was no significant difference in baseline characteristics between the intervention and placebo groups in terms of mean age, sex, and mean admission BI (p > 0.05). Mean (SD) admission BI in placebo and intervention groups was 27.20 (7.341) and 27.87(5.78), respectively (p = 0.784). The measured mean (SD) BI after treatment was 48.73 (15.54) in the placebo and 64.93 (11.81) in the intervention group (p = 0.003) after 3 weeks. CONCLUSION: Using fampridine plus IVMP in the acute phase of transverse myelitis in MS patients improved the disease's symptoms and increased the daily activity ability of patients.

Viral Versus Vaccine-Associated Acute Transverse Myelitis With Neuromyelitis Optica Immunoglobulin G Antibody and Myelin Basic Protein: A Case Report.

Transverse myelitis is a rare spinal cord disorder caused by local inflammation. Usually, this occurs as a complication from infection or autoimmune disease; however, there have been reported idiopathic causes such as vaccinations. A 73-year-old female with a medical history significant for Hashimoto's thyroiditis presented with new-onset paresthesias in her lower extremities. Her symptom onset was about five weeks after receiving influenza and tetanus, diphtheria, and pertussis (TDaP) vaccines. Magnetic resonance imaging (MRI) of the spine revealed an increased T2 signal of the lower cervical and thoracic spine. Lumbar puncture was also performed, and cerebrospinal fluid (CSF) serology showed elevated myelin basic protein (MBP) at 108.3 ng/mL (reference range: 0-5.5 ng/mL). Serology panel revealed Coxsackie virus type B4 antibody at 1:80 (reference range: <1:10) and Echovirus type 6 antibody at 1:640 (reference range: <1:10). Neuromyelitis optica (NMO) immunoglobulin G (IgG) antibody was 24.6 U/mL (reference range: <2.9 U/mL). She was diagnosed with acute transverse myelitis (ATM) and treated with alternating steroids and plasma exchange (PLEX) therapy for five days each. This case highlights the possible associations of vaccines with transverse myelitis. Although ATM is a rare disorder with serious complications, it has a favorable prognosis in the setting of rapid detection and treatment. Vaccine-related ATM remains controversial, but patients with these adverse reactions need to be cautioned regarding potential recurrence risk.

Two Case Reports of Patients With Transverse Myelitis as a Complication of SARS-CoV-2 Infection.

Transverse myelitis is a nontraumatic spinal cord injury that presents with sudden onset weakness, sensory deficits, and autonomic dysfunction. It can be caused by multiple etiologies including malignancy, autoimmune disorders, viral, bacterial, or fungal infections, and environmental factors. In this article, we describe cases of two elderly male patients affected by the SARS-CoV-2 virus. Patients did not exhibit classic or had only mild classic symptoms of SARS-CoV-2 infection; however, both patients developed transverse myelitis. Patients were treated with intravenous steroids and therapeutic plasmapheresis, achieving partial improvement. The study aimed to understand rare complications like transverse myelitis of SARS-CoV-2 infection and treatment accordingly.

Transverse myelitis in a 26-year-old male with tuberculosis.

Acute transverse myelitis is an inflammatory condition covering the entire cross section of the spinal cord, spreading on two or more vertebral segments, without evidence of a compressive lesion. This shows clinically as an acute or subacute onset of paraparesis, lower limb paresthesia, sensory deficits, and impaired sphincter function. Mycobacterium tuberculosis is exceedingly rare cause of this inflammation, with a mechanism still not fully understood. The main etiologies are thought to be an abnormal activation of the immune system against the neuronal cells of the medulla, direct inoculation of the bacillus, and the toxic effect of the antitubercular medications on the spinal cord. We present the case of a 26-year-old male patient with acute symptoms of transverse myelitis and presence of miliary tuberculosis of the lungs. The purpose of this case report is to put the emphasis on the importance of distinguishing the characteristics of tubercular lesions on imaging modalities, especially on magnetic resonance imaging, in the differential diagnosis of tuberculosis as a rare but profoundly serious cause of acute transverse myelitis.

A Case Presenting with Neuromyelitis Optica Spectrum Disorder and Infectious Polyradiculitis Following BNT162b2 Vaccination and COVID-19.

A 37-year-old woman presented with paraparesis and paresthesia in both legs 19 and 3 days after BNT162b2 vaccination and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, respectively. Cerebrospinal fluid (CSF) analysis, nerve conduction study, electromyography, magnetic resonance imaging, and autoantibody tests were performed. Neurological examination showed hyperesthesia below the T7 level and markedly impaired bilateral leg weakness with absent deep tendon reflexes on the knees and ankles. CSF examination revealed polymorphonuclear dominant pleocytosis and elevated total protein levels. Enhancement of the pia mater in the lumbar spinal cord and positive sharp waves in the lumbar paraspinal muscles indicated infectious polyradiculitis. In contrast, a high signal intensity of intramedullary spinal cord on a T2-weighted image from C1 to conus medullaris and positive anti-aquaporin-4 antibody confirmed neuromyelitis optica spectrum disorder (NMOSD). The patient received intravenous methylprednisolone, antiviral agents, and antibiotics, followed by a tapering dose of oral prednisolone and azathioprine. Two months after treatment, she was ambulatory without assistance. The dual pathomechanism of NMOSD triggered by coronavirus disease 2019 (COVID-19) vaccination and polyradiculitis caused by SARS-CoV-2 infection may have caused atypical clinical findings in our patient. Therefore, physicians should remain alert and avoid overlooking the possibilities of diverse mechanisms associated with neurological manifestations after SARS-CoV-2 infection and COVID-19 vaccination.