Physical exam showed a temperature of 100.5F, heart rate of 148, respiratory rate of 30, blood pressure 103/70, and a weight of 10.5 kg (90%). Patient is well developed and well nourished without any acute distress. Physical exam was pertinent for supple neck with head lag, generalized weakness with decreased muscular strength in the upper and lower extremities. Upper extremities strength was 4/5 and lower extremities were 3/5. Neck laxity was present, sitting required support, and she refused to stand. Neurologically the patient was alert with reflexes mildly decreased in the lower extremities.
Laboratory evaluation included a complete blood count with a white blood cell (WBC) count of 11.7 and of hemoglobin of 11.4. A comprehensive metabolic panel was within normal limits. Lumbar puncture showed glucose of 50, protein of 38, 2 WBCs, 2 red blood cells, and a negative gram stain. Urinalysis was negative. Erythrocyte sedimentation rate was 17, CPK was 57, and chest radiograph was negative.
FIGURE 1.
At this time stool was sent for botulism toxin; however, there was no history of eating canned food or honey. While waiting for results the patient showed slight improvement in movement and activity and demonstrated good oral intake. Physical therapy and speech therapy were working with the patient and lower extremity movement was improving, but she still had diffi culty standing. At this time an MRI of the brain and cervical spine was ordered and showed an intramedullary lesion involving the cervical and upper thoracic cord with localized cord enlargement. Enhancement was seen along C5 and C6 to the T1 level without canal stenosis and normal anatomic alignment was noted (Figure 1). In the meantime, stool for botulism toxin returned negative. Treatment was started for the diagnosis of transverse myelitis and included dexamethasone 2 mg/kg once daily with a taper over 5 weeks. She had minimal improvement prior to discharge, but showed slow and steady resolution of symptoms. Follow up with neurology was to be done on an outpatient basis, as well as continuation of physical therapy and occupational therapy.
Discussion
Transverse myelitis or transverse myelopathy (TM) is a syndrome of acute or subacute inflammation involving the spinal cord with partial or complete loss of neurologic function. It is usually limited to a number of spinal segments. The incidence is 1.3 new cases per one million residents annually. It affects all ages and both sexes; however, is uncommon in children less than 10 years of age. There are three theories for the etiology: cell-mediated autoimmune inflammation and/or demyelination of the spinal cord, a direct viral infection of the cord, and a paraneoplastic remote effect of cancer.
Clinical features include abrupt onset of symptoms varying from hours to a few days. One third of patients have a preceding viral illness. An early sign is muscle weakness, especially of the lower limbs. There may be numbness at the midthoracic region, strength loss as extreme as paraplegia, loss of bowel or bladder control, or sensory loss, most commonly involves pain and temperature. Fifty percent may experience a sharp, gnawing back pain at the level of the myelitis. Progression of the disease can lead to spasticity and hyperreflexia.
There is not a confirmation of any pathophysiologic mechanism. Demyelination, neuronal injury, and incomplete or complete necrosis of neural tissue may be associated with inflammatory changes on biopsy.
Differential diagnosis includes idiopathic autoimmune transverse myelitis, acute disseminated encephalomyelitis, multiple sclerosis (MS), Guillain-Barre, viral myelitis, vasculitis, spinal cord infarction, paraneoplastic myelopathy, vascular malformations, and nutritional myelopathy. Additionally, infectious etiologies include HIV myelopathy, spirochetal infection, and poliomyelitis.
Diagnosis is by exclusion. First, a mechanical, compressive lesion must be excluded from the differential. MRI of the spine visualizes the myelin and excludes compression and is used primarily to exclude these possible etiologies. MRI of the brain is useful to diagnose multiple sclerosis. Lumbar puncture results are variable ranging from normal to nonspecifi c inflammatory changes including a mild increase in protein or leukocytosis with an increase in polymorponuclear cells. Glucose is usually normal.