Transverse myelitis

Demographic and clinical characteristics of patients with transverse myelitis and traumatic spinal cord injury: A comparative retrospective study

OBJECTIVES

To identify the demographic and clinical characteristics of patients with transverse myelitis (TM) and to compare functional status between those patients and a matched group with traumatic spinal cord injury (T-SCI).

STUDY DESIGN

Retrospective study.

SETTING

A tertiary rehabilitation hospital.

PARTICIPANTS

The demographic and clinical characteristics of 484 T-SCI patients and 25 TM patients were compared. Functional status was further analyzed by matching the two groups.

OUTCOME MEASUREMENTS

The matched patients were compared in terms of motor and sensory functions, bladder and bowel symptoms, ambulation level, the Rivermead Mobility Index, and SCI-related medical complications.

RESULTS

The mean age of the TM patients was 35.6 years and was similar to that of the T-SCI patients. There were significantly more females in the TM group (P = 0.017). Individuals with TM had fewer cervical injuries (P = 0.032) and a higher rate of paraplegia (P = 0.047) and were more often incomplete (P = 0.009) than those with T-SCI. Sensory function was significantly better in the TM group compared to the matched T-SCI group (P = 0.05). Independent ambulation frequency was higher in the TM patients. The SCI-related complications seen in the TM group were as common as those in the T-SCI group.

CONCLUSION

The TM and T-SCI groups differed in terms of the demographic and clinical characteristics recorded. Additionally, when matched for these differences, functional status was slightly better in the TM group. However, like T-SCI, TM was a significant cause of disability and SCI-related complications were common.

Longitudinally Extensive Transverse Myelitis Associated with Cytomegalovirus Infection in an Immunocompetent Patient

Longitudinally extensive transverse myelitis (LETM) associated with cytomegalovirus infection is extremely rare and is, mainly observed in immunocompetent people. A 55-year-old woman with no evidence of immunosuppression was admitted with paresthesia in the lower limbs for 15 days, difficulty walking, fecal incontinence, and acute urinary retention. Magnetic resonance imaging (MRI) in the T2 sequence showed signs of hyperintensity in the cervical and thoracic cord. The serological study showed IgM antibodies to cytomegalovirus, and the result of the FilmArray meningitis/encephalitis panel showed the presence of cytomegalovirus. She received treatment with methylprednisolone and ganciclovir with a favorable outcome. This case highlights the importance of investigating treatable causes in patients with longitudinally extensive transverse myelitis with acute presentation.

Magnetic Resonance Imaging for Spine Emergencies

This article is devoted to the MR imaging evaluation of spine emergencies, defined as spinal pathologic conditions that pose an immediate risk of significant morbidity or mortality to the patient if not diagnosed and treated in a timely manner. MR imaging plays a central role in the timely diagnosis of spine emergencies. A summary of MR imaging indications and MR imaging protocols tailored for a variety of spinal emergencies will be presented followed by a review of key imaging findings for the most-encountered emergent spine pathologic conditions. Pathologic conditions will be broadly grouped into traumatic and atraumatic pathologic conditions. For traumatic injuries, a practical and algorithmic diagnostic approach based on the AO Spine injury classification system will be presented focused on subaxial spine trauma. Atraumatic spinal emergencies will be dichotomized into compressive and noncompressive subtypes. The location of external compressive disease with respect to the thecal sac is fundamental to establishing a differential diagnosis for compressive emergencies, whereas specific patterns of spinal cord involvement on MR imaging will guide the discussion of inflammatory and noninflammatory causes of noncompressive myelopathy.

COVID-19 Vaccination and the Rate of Immune and Autoimmune Adverse Events Following Immunization: Insights From a Narrative Literature Review

Despite their proven efficacy and huge contribution to the health of humankind, vaccines continue to be a source of concern for some individuals around the world. Vaccinations against COVID-19 increased the number of distressed people and intensified their distrust, particularly as the pandemic was still emerging and the populations were encouraged to be vaccinated under various slogans like "back to normal life" and "stop coronavirus", goals which are still to be achieved. As fear of vaccination-related adverse events following immunization (AEFIs) is the main reason for vaccine hesitancy, we reviewed immune and autoimmune AEFIs in particular, though very rare, as the most worrisome aspect of the vaccines. Among others, autoimmune AEFIs of the most commonly administered COVID-19 vaccines include neurological ones such as Guillain-Barre syndrome, transverse myelitis, and Bell's palsy, as well as myocarditis. In addition, the newly introduced notion related to COVID-19 vaccines, "vaccine-induced immune thrombotic thrombocytopenia/vaccine-induced prothrombotic immune thrombotic thrombocytopenia" (VITT/VIPITT)", is of importance as well. Overviewing recent medical literature while focusing on the major immune and autoimmune AEFIs, demonstrating their rate of occurrence, presenting the cases reported, and their link to the specific type of COVID-19 vaccines represented the main aim of our work. In this narrative review, we illustrate the different vaccine types in current use, their associated immune and autoimmune AEFIs, with a focus on the 3 main COVID-19 vaccines (BNT162b2, mRNA-1273, and ChAdOx1). While the rate of AEFIs is extremely low, addressing the issue in this manner, in our opinion, is the best strategy for coping with vaccine hesitancy.

Acute Transverse Myelitis in Pregnancy: The Use of ProSeal Laryngeal Mask Airway Without Curarization for Emergency Cesarean Section

Transverse myelitis is a rare inflammatory neurological disorder of the spinal cord that damages the myelin covering the spinal cord and thus produces sensory, motor, and autonomic symptoms. A 26-year-old primigravida of 40 weeks gestation presented to the obstetric emergency of our hospital with complaints of weakness in both lower limbs and inability to walk for four days. A diagnosis of acute transverse myelitis was made, and due to fetal distress and arrest of labor in the second stage, an emergency cesarean section was planned. Considering the risks associated with the neuraxial technique and muscle relaxants, cesarean section was planned under general anesthesia and was successfully done with ProSeal laryngeal mask airway (LMA) using propofol and sevoflurane without muscle relaxant.

A 42-Year-Old Man with Back Pain and Lower Extremity Weakness

Back Pain and Lower-Extremity WeaknessA 42-year-old man with HIV presented for evaluation of acute-onset back pain and lower-extremity weakness. How do you approach the evaluation, and what is the diagnosis?

Neurological and neuropsychological adverse effects of SARS-CoV-2 vaccines - where do we stand?

The devastating characteristic of COVID-19 pandemic calls for immediate and effective solutions to tackle it. Vaccines seem to be the only promising and effective way to fight against the novel coronavirus - even against new mutated variants. Because of the rapid development and distribution of numerous COVID-19 vaccines in different platforms, meticulous evaluation of vaccines' safety is more critical than ever - especially given the fact that most of the candidates have not completed the clinical phase. Therefore, to optimize the vaccines' safety and efficacy, it is highly important to carefully report and scientifically discuss the serious adverse effects following vaccination. In this respect, we discuss different neurological and neuropsychological adverse effects of COVID-19 vaccines including demyelinating diseases, Bell's palsy (BP), cerebrovascular complications, seizures, functional neurological disorders (FNDs), and some other rare adverse events, and hypothetical mechanisms which can lead to the reported side effects. Given the fact that the incidence of such events are rare and most of them are treatable, the current review aims to shed light on how much the relationship between COVID-19 vaccines and these complications can be reliable and provide an insight for future studies with much more meticulous methodologies to discuss the possible correlational or causal relationship between these complications and COVID-19 vaccines and elucidate whether or not the neurological side effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines can count as a considerable threat to public health.

Transverse Myelitis Associated with Cryptococcus neoformans in an Immunocompetent Patient

Cryptococcus neoformans is a microscopic fungus that despite its pervasiveness in the environment rarely causes infection in immunocompetent patients. In immunosuppressed patients, infections involving the central nervous system (CNS) usually present as meningitis or meningoencephalitis. Cryptococcal infections are known to cause significant morbidity and mortality in immunosuppressed patients as it is difficult to eradicate even with adequate antifungal treatment. A 44-year-old Hispanic male presented to the hospital with headache, progressive urinary retention, neck and back pain, and right upper and bilateral lower extremity weakness for five days. Imaging revealed small foci in the white matter and revealed diffuse abnormal signal involving the cervical medullary junction extending up to the thoracic spine. Analysis of cerebral spinal fluid (CSF) obtained via lumbar puncture was positive for the Streptococcus antigen with cultures also growing Cryptococcus neoformans. Upon evaluation, patient was not found to be immunocompromised. This report works to highlight an atypical presentation of a cryptococcal CNS infection to raise awareness amongst clinicians hoping to prevent a delay in diagnosis of this disease given its high mortality.

Interstitial Lung Disease and Transverse Myelitis: A Possible Complication of COVID-19 Vaccine

The clinical impact of the severe acute respiratory syndrome 2 (SARS-CoV-2) pandemic is growing, and vaccine-associated complications are becoming more evident. Although global vaccination against coronavirus disease 19 (COVID-19) is an outstanding accomplishment, safety concerns and adverse outcomes are also emerging that need to be addressed promptly. The most reported side effects of the COVID-19 vaccine include fever, myalgia, headache, and injection site reactions. Acute transverse myelitis (ATM) and interstitial lung disease (ILD) following the CoronaVac vaccine are rarely reported. We report a case of ILD followed by acute myelopathy in a female who presented with dyspnea, cough, and fever after the second dose of the COVID-19 vaccine. On the third day of admission, she developed paresthesia and bilateral upper and lower limb weakness. She was diagnosed with ILD and ATM due to the COVID-19 vaccine based on imaging and detailed investigations after ruling out all possible causes. Her neurological and respiratory manifestations improved gradually after starting intravenous methylprednisolone.

Neurological Conditions Following COVID-19 Vaccinations: Chance or Association?

Coronavirus disease 2019 (COVID-19) has been labeled a global pandemic with the first reported case of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) occurring in Wuhan, China in December 2019. To combat the alarming, increasing rate of those affected by the virus, vaccine development ensued. As mass vaccination initiatives against COVID-19 ensued, adverse reactions began emerging. This non-consecutive, population-based case series focuses on four vaccine-associated neurological adverse events across the central and peripheral nervous system detailing the diagnosis, treatment and subsequent follow-up management. These four patients presented to public and private hospitals in Trinidad and Tobago with new-onset neurological diseases soon after their first doses of a COVID-19 vaccine: two after the Pfizer-BioNTech vaccine (one case of new-onset seizures and one case of longitudinally extensive transverse myelitis) and two after the ChAdOx1 nCoV-19 vaccine (one case of Guillain-Barre syndrome and one case of meningitis-retention syndrome). The background incidence rates of neurological conditions in the population and the large numbers of persons being vaccinated means that some of these conditions will appear in the post-vaccination window by chance. Hence, establishing causal links is difficult. The close temporal relationship between vaccination and the presenting symptoms, the biological plausibility, and the extensive diagnostic workup to exclude other causes fulfill criteria provided by the World Health Organization for causality assessment of an adverse event following immunization on an individual level. On this basis, it was determined that these adverse events were likely due to the vaccines. However, establishing causal links on a population level requires large epidemiological studies and cannot be done on individual case reports alone. While physicians should be cognizant of even these rare adverse events of vaccines, it should be reiterated that the overall safety profile of vaccines is well established.

Inflammatory Disease Affecting the Central Nervous System in Dogs: A Retrospective Study in England (2010–2019)

The epidemiology of inflammatory diseases affecting the central nervous system (CNS) in dogs is largely unknown. We aimed to report the relative proportion of different causes of inflammatory disease affecting the CNS in dogs and identify predictors for infectious vs. immune-mediated conditions and predictors for the most common diseases affecting the brain and the spinal cord. This was a retrospective cohort study over a 10-year period in 2 referral institutions using multivariable and multinomial logistic regression for identification of risk factors. In total, 1,140 client-owned dogs diagnosed with inflammatory disease affecting the CNS were included. Fifteen different diagnoses were identified, with immune-mediated (83.6%) disease being more common than infectious conditions (16.4%). The most common immune-mediated conditions diagnosed were meningoencephalitis of unknown origin (47.5%) and steroid-responsive meningitis–arteritis (30.7%), and the most common infectious conditions were discospondylitis (9.3%) and otogenic intracranial infection (2.2%). Older age (p < 0.001, OR = 1.019, 95% CI: 1.014–1.024), higher body weight (p < 0.001, OR = 1.049, 95% CI: 1.025–1.074), male sex (p = 0.009, OR = 1.685, 95% CI: 1.141–2.488), longer duration of the clinical signs before presentation (p < 0.001, OR = 1.011, 95% CI: 1.006–1.017), progressive nature of the clinical signs (p < 0.001, OR = 2.295, 95% CI: 1.463–3.599), identification of a possibly associated preceding event (p = 0.0012, OR = 1.93, 95% CI: 1.159–3.213), and hyperesthesia on presentation (p < 0.001, OR = 2.303, 95% CI: 1.528–3.473) were associated with a diagnosis of infectious diseases. Our data shows that immune-mediated diseases are more common than infectious conditions as a cause for inflammatory CNS disease in dogs. The risk factors for the most common diagnoses were identified from signalment, history, and findings of the physical and neurological examinations to give valuable information that can guide clinicians with their investigations.

A systematic review of cases of CNS demyelination following COVID-19 vaccination

BACKGROUND

Since the emergency use approval of different types of COVID-19 vaccines, several safety concerns have been raised regarding its early and delayed impact on the nervous system.

OBJECTIVE

This study aims to systematically review the reported cases of CNS demyelination in association with COVID-19 vaccination, which has not been performed, to our knowledge.

METHODS

A systematic review was performed by screening published articles and preprints of cases of CNS demyelination in association with COVID-19 vaccines in PubMed, SCOPUS, EMBASE, Google Scholar, Ovid and medRxiv databases, until September 30, 2021. This study followed PRISMA guidelines. Descriptive findings of reported cases were reviewed and stratified by demographic and clinical findings, diagnostic work-up, management, and overall outcome.

RESULTS

A total of 32 cases were identified, with female predominance (68.8%) and median age of 44 years. Eleven cases were reported after Pfizer vaccine, 8 following AstraZeneca vaccine, 6 following Moderna, 5 following Sinovac/ Sinopharm vaccines, and one following each of Sputnik and Johnson&Johnson vaccines. The majority of cases (71.8%) occurred after the first dose of the vaccine, with neurological symptoms manifesting after a median of 9 days. The most common reported presentations were transverse myelitis (12/32) and MS-like pictures (first diagnosis or a relapse) in another 12/32 cases, followed by ADEM- like (5/32), and NMOSD- like (3/32) presentations. History of a previous immune-mediated disease was reported in 17/32 (53.1%) cases. The mRNA-based vaccines resulted in the greatest number of demyelinating syndromes (17/32), followed by viral vector vaccines (10/32), and inactivated vaccines (5/32). Most MS-like episodes (9/12) were triggered by mRNA-based vaccines, while TM occurred following both viral vector and mRNA-based vaccines. Management included high dose methylprednisolone, PLEX, IVIg, or a combination of those, with a favorable outcome in the majority of case; marked/complete improvement (25/32) or stabilized/ partial recovery in the remaining cases.

CONCLUSION

This systematic review identified few cases of CNS demyelination following all types of approved COVID-19 vaccines so far. Clinical presentation was heterogenous, mainly following the first dose, however, half of the reported cases had a history of immune-mediated disease. Favorable outcome was observed in most cases. We suggest long-term post-marketing surveillance for these cases, to assess for causality, and ensure the safety of COVID-19 vaccines.

Clinical Problem-Solving: Lower Extremity Weakness & Paresthesia in an Immunocompromised Patient With a Complex Cancer History

We present a case of new onset bilateral lower extremity weakness, paresthesia, urinary retention and bowel incontinence in a 51-year-old man. He had a complicated history of acute myelogenous leukemia with known central nervous system (CNS) and leptomeningeal involvement status post allogenic stem cell transplant complicated by chronic graft versus host disease (GVHD). We review the differential diagnosis as the physical exam and diagnostic results evolved. We also provide a review of the relevant literature supporting our favored diagnosis, as well as other competing diagnoses in this complicated case. The ultimate differential diagnosis included viral myelitis, treatment-related myelopathies, and CNS GVHD. The case provides a sobering reminder that even with an appropriate diagnostic workup, some cases remain refractory to therapeutic efforts. It also underscores the importance of a sensitive neurologic exam, given the significant clinico-radiological delay, and reviews the complex differential diagnosis for myelopathy.

Clinical approach to neuro-rheumatology

Recognizing the neurologic manifestations of systemic rheumatologic diseases and certain isolated autoimmune neurologic diseases poses challenges to the clinician. Using a systematic approach allows the clinician to diagnose these conditions more readily and to initiate treatment more rapidly. Specific neurological syndromes frequently associated with rheumatologic or specific autoimmune conditions can suggest the diagnosis. A targeted history and examination can identify neurological and systemic clues that help to identify an underlying rheumatologic condition. Judicious use of laboratory and radiographic studies can help confirm suspected diagnoses. This article will review some of the neurological syndromes typical of rheumatologic disease and outline an approach to evaluating for unknown rheumatologic disease in this context.

Post-COVID-19 Acute Transverse Myelitis: A Case Report and Literature Review

Acute transverse myelitis (ATM) following coronavirus disease 19 (COVID-19) is rarely reported in the literature. We report a case of ATM after COVID-19 infection in a female who presented with sudden onset bilateral lower limb weakness, paresthesia, and urinary retention. She developed fever, cough, dyspnea two weeks ago, and her COVID-19 test was positive one week later. After a complete physical examination and detailed investigations, including cerebrospinal fluid analysis, autoimmune screening, and infectious workup, a diagnosis of ATM due to COVID-19 was made. Magnetic resonance imaging of the whole spine confirmed the diagnosis of ATM. She was managed with intravenous methylprednisolone, physical therapy, and bladder training and her condition improved gradually.

Post-COVID-19 longitudinally extensive transverse myelitis: is it a new entity?

Introduction

To the best of our knowledge, here we present two post-COVID19 longitudinally extensive transverse myelitis (LETM) with atypical presentations

Case presentations

A 44-year-old male who did not have any previous medical condition and a 73-year-old male foreigner who did not have any disease other than type 2 diabetes mellitus were admitted to our neurology clinic in the same period with similar clinical presentations of transverse myelitis. Upon admission, paraplegia and urinary-fecal incontinence were observed in their neurological examination. Neurological complaints had started within approximately 3–4 weeks following the resolution of the COVID-19 infection. Thoracic lower segment LETM was observed on spinal magnetic resonance imaging (MRI) in one of the patients, and long segment myelitis extending from the lower thoracic segment to the conus medullaris was observed in the other one. No significant diagnostic positivity was present in their diagnostic evaluation. In both cases, we assume a post-infectious etiology in terms of secondary immunogenic overreaction following COVID-19.

Conclusion

Our patients improved with multiple treatments such as methylprednisolone, intravenous immunoglobulin, and plasmapheresis. Whether post-infectious myelitis behaves differently from other viral infections after COVID-19 is currently unclear. Long lag times appear to be a post-infectious neurological complication resulting from the host response to the virus.

Approach to Myelopathy and Myelitis

Myelopathy can present acutely or more insidiously and has a broad differential diagnosis. In addition to the clinical history and neurologic examination, diagnostic testing, including MRI and cerebrospinal fluid analysis, as well as thorough review of patient comorbidities, risk factors, and potential toxic exposures, can help neurohospitalists distinguish between various causes and potentially start appropriate empiric therapy while awaiting definitive testing. This article focuses on how imaging can help in determining the most likely cause of myelopathy and highlights a range of causes, including compressive, vascular, metabolic and toxic, infectious, autoimmune, neoplastic, and paraneoplastic causes of spinal cord dysfunction.

An Uncommon Cause of Acute Transverse Myelitis Following Acinetobacter Baumannii-Associated UTI, Which Responded to Intravenous Pulse Methylprednisolone Alone

Acute transverse myelitis (ATM) is a non-compressive localized inflammation involving one or more levels of the spinal cord due to various etiologies characterized by motor weakness, sensory impairments, and autonomic dysfunction. It can be idiopathic or primary or secondary due to infection, autoimmune disorder, connective tissue disorder, and uncommonly after vaccination which came to the limelight during the ongoing massive vaccine drive against coronavirus disease 2019 (COVID-19). We report a case of a 21-years-old male who presented with gradually progressive weakness of both lower limbs following urinary tract infection (UTI) with a history of similar illness in the family which improved with high dose methylprednisolone and antibiotic therapy followed by physical rehabilitation. A diagnosis of long segment ATM possibly following UTI was suggested after ruling out other secondary causes and was confirmed by magnetic resonance imaging (MRI) of the spinal cord. Asymmetric symptoms and signs with small lesions involving <two vertebral segments, peripheral lesion, presence of Lhermitte's sign and relapsing-remitting course distinguish ATM from more debilitating disorder multiple sclerosis (MS) in patients with family history. Infection like UTI can precipitate ATM as well as UTI may develop along with neurogenic lower urinary tract dysfunction (NLUTD) even after recovery from the motor and sensory impairment. Patients with acute transverse myelitis need to be on regular follow up particularly those with subacute presentation and positive family history to rule out relapse and development of multiple sclerosis. Common etiologies like UTI may precipitate uncommon disorders like ATM.

Acute Transverse Myelitis Following COVID-19 Infection: A Rare Case From Saudi Arabia

Respiratory viral illnesses can lead to a wide variety of neurological complications. However, only a few cases of acute transverse myelitis (ATM) following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported in the literature. Here, we report a case of ATM following SARS-CoV-2 infection in a 57-year-old male patient. The patient presented to the emergency room with lower abdominal pain, urinary retention, bilateral lower limbs weakness, and allodynia for the last four days. One week earlier, he had experienced fever, cough, and shortness of breath. On physical examination, he was vitally stable with sensory loss from the nipples down to the lower limbs bilaterally. His nasopharyngeal polymerase chain reaction for SARS-CoV-2 was positive. MRI of the spine showed an abnormal cord signal extending from the level of the D2 vertebra down to the conus medullaris. The main differential diagnosis was transverse myelitis, and the patient was started on pulse steroids for seven days. After the therapy, the condition of the patient improved with the restoration of power and sensory sensation in his lower limbs. A new MRI of the whole spine one month later showed normal morphology and signal intensity without any abnormal enhancement. The patient was discharged home with almost complete resolution of his symptoms for later follow-up in the clinic.

Infection-Related Myelopathies

Recent years have seen growing attention to inflammatory and infectious disorders of the spinal cord, not only due to the discovery of autoantibody-mediated disorders of the spinal cord [e.g., aquaporin-4 immunoglobulin G (IgG) antibodies and myelin oligodendrocyte glycoprotein IgG antibodies], but also due to the emergence of clusters of infection-related myelopathy, now known as acute flaccid myelitis. We review the spectrum of infection-related myelopathies and outline a nosological classification system based on association with infection. We describe the epidemiology and definitions of myelopathies, with a discussion of clinical presentation and neuroimaging features, and then turn to specific discussion of myelopathies due to direct pathogen invasion and those considered to be post- or parainfectious. Expected final online publication date for the Annual Review of Pathology: Mechanisms of Disease, Volume 17 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Acute transverse myelitis revealing ankylosing spondylitis: A case report and literature review

When faced with a patient with acute myelopathy, thorough investigations should be undertaken to determine the cause. Ankylosing spondylitis should be kept in mind as a possible cause.

Neuroimmunology and Novel Methods of Treatment for Acute Transverse Myelitis

Acute transverse myelitis (ATM) is a rare, immune-mediated pathology that is defined as an adverse inflammatory response in the spinal cord leading to neurologic injury. The pathophysiology of ATM is poorly understood, with no apparent differences in age, ethnicities, or race, along with variable radiographic and clinical presentation. Therefore, in this review, we will characterize what is known about ATM's etiology and diagnostic criteria, and relate it to properties of neuroimmunology. Moreover, we will further discuss current treatment options, along with potential novel methods, to provide a comprehensive overview of the status of ATM's research development. Among these novel treatments, potassium blockers reveal exciting early outcomes in restoring neurologic motor function. In addition, human glial progenitor cell transportations have been described as a potential treatment through integrating and remyelinating lesion sites. Nevertheless, despite these novel methods, there is a paucity of clinical trials establishing ATM's immunopathology and the therapeutic role of potential treatment methods. Therefore, we will highlight the importance of larger well-designed clinical trials in revealing significant biomarkers of injury and recovery.

Modern Look at Transverse Myelitis and Inflammatory Myelopathy: Epidemiology of the National Veterans Health Administration Population

BACKGROUND AND OBJECTIVES

To characterize population-level data associated with transverse myelitis (TM) within the US Veterans Health Administration (VHA).

METHODS

This retrospective review used VHA electronic medical record from 1999 to 2015. We analyzed prevalence, disease characteristics, modified Rankin Scale (mRS) scores, and mortality data in patients with TM based on the 2002 Diagnostic Criteria.

RESULTS

We identified 4,084 patients with an International Classification of Diseases (ICD) code consistent with TM and confirmed the diagnosis in 1,001 individuals (90.7% males, median age 64.2, 67.7% Caucasian, and 31.4% smokers). The point prevalence was 7.86 cases per 100,000 people. Less than half of the cohort underwent a lumbar puncture, whereas only 31.8% had a final, disease-associated TM diagnosis. The median mRS score at symptom onset was 3 (interquartile range 2-4), which remained unchanged at follow-up, although less than half (43.2%) of the patients received corticosteroids, IVIg, or plasma exchange. Approximately one-quarter of patients (24.3%) had longitudinal extensive TM, which was associated with poorer outcomes (p = 0.002). A total of 108 patients (10.8%) died during our review (94.4% males, median age 66.5%, and 70.4% Caucasian). Mortality was associated with a higher mRS score at follow-up (OR 1.94, 95% CI, 1.57-2.40) and tobacco use (OR 1.87, 95% CI, 1.17-2.99).

DISCUSSION

This national TM review highlights the relatively high prevalence of TM in a modern cohort. It also underscores the importance of a precise and thorough workup in this disabling disorder to ensure diagnostic precision and ensure optimal management for patients with TM in the future.

Covid-19 post-infectious acute transverse myelitis responsive to corticosteroid therapy: report of two clinical cases

SARS-COV-2 infection has affected millions of individuals with a wide range of clinical manifestations, including central and peripheral nervous systems through several mechanisms. A rare but potentially severe manifestation of this virus is transverse myelitis. Herein, we report on two patients who developed paraparesis, sensory deficit, and autonomic changes on the tenth day after infection by COVID-19. A 27-year-old man, previously healthy, had symptoms of COVID-19 confirmed by oropharyngeal and nasopharyngeal swab tests. On the tenth day of symptoms, the patient started to experience acute paraparesis, urinary retention, constipation, and hypoesthesia up to the T4 level. The second patient is a 50-year-old man, previously healthy, who had symptoms of the flu-like syndrome. The diagnosis of COVID-19 infection was confirmed by oropharyngeal and nasopharyngeal swab tests. On the tenth day of symptoms, the patient started to experience paraparesis, urinary incontinence, and hypoesthesia up to the T6 level. The neuroimaging and cerebrospinal fluid (CSF) analysis of both patients confirmed acute transverse myelitis after COVID-19 infection. High-dose corticosteroid therapy was started, and both patients showed rapid recovery from their deficits. Although rare, post-infectious transverse myelitis may be related to SARS-COV-2 infection and should be quickly recognized. Although controlled studies are needed, treatment with corticosteroid therapy in high doses was effective in these patients.

Longitudinally extensive transverse myelitis with positive aquaporin-4 IgG associated with dengue infection: a case report and systematic review of cases

BACKGROUND

Neuromyelitis Optica Spectrum Disorder can be associated with parainfectious and post-infectious triggers. Dengue virus infection is one of the most common arbovirus infections in the world, and may present with neurological manifestations.

OBJECTIVES

We present a case of DENV-associated with LETM and positive aquaporin-4 IgG, and a systematic review of published cases.

METHODS

Medline (Ovid) and PubMed were search through June 2021, for case reports, series and observational studies that described patients with DENV-associated LETM and/or NMOSD.

RESULTS

An adolescent girl who had recently immigrated from a Dengue-endemic region presented with a LETM with high positive AQP4-IgG titer and seropositive DENV IgM/IgG antibodies. She responded well to steroids and subsequently started maintenance rituximab for her NMOSD diagnosis.

LITERATURE REVIEW

22 publications describing 27 patients met inclusion criteria. In addition to this case, three published cases met current criteria for NMOSD with serological evidence of acute DENV infection.

CONCLUSIONS

It is unknown whether there is a pathophysiological association between DENV infection and NMOSD. Regardless, if an immune-mediated event is suspected, particularly NMOSD, appropriate immunotherapy should be considered early. Decision regarding long term immunotherapy may depend on index of suspicion of true NMOSD, and this is where AQP4-IgG status and follow-up is helpful.

Bladder management in children with transverse myelitis

BACKGROUND

Patients with transverse myelitis (TM) often present with urinary retention. While many recover their bladder function, some have persistent voiding dysfunction, and both intermediate and long-term outcomes are variable.

OBJECTIVE

In patients who develop urinary retention requiring clean intermittent catheterization (CIC) at onset of TM, we sought to assess factors associated with improved voiding function and the risk of requiring persistent CIC over time.

STUDY DESIGN

We reviewed children evaluated at our institution for TM from April 1998 to October 2018. Patients were included if they required CIC at initial presentation of TM. Demographics, initial and follow up neurologic exams were evaluated for their association with a return to baseline volitional voiding after requiring catheterization upon diagnosis of TM, with or without medical therapy.

RESULTS

Among the 78 patients who presented with TM during the study period, 43 patients required CIC, with median follow up of 2.7 years. When evaluating for demographic or sensorimotor features associated with improvement to baseline voiding function in patients who initially required CIC, preserved lower extremity reflexes at presentation was the only significant prognostic factor (p < 0.05). Additionally, having complete lower motor neurologic recovery was associated with volitional voiding (p < 0.05). Among the 43 patients who were initially catheterizing, 27/43 (62%) were volitionally voiding at median follow up of 7 months from initial presentation, while the remaining 16/43 remained on CIC for a median follow up of 3.6 years. The cumulative risk of remaining on CIC was 60%, 47%, and 42% at 1, 5, and 10 year follow up, respectively, though there was not a significant difference in the rate of bladder recovery if patients had preserved reflexes.

DISCUSSION

In children with TM who initially developed urinary retention, intact reflexes at presentation were associated with urologic recovery. Additionally, complete neurologic recovery was associated with volitional voiding. While 62% were volitionally voiding at most recent follow-up, the cumulative incidence of dependence on CIC within the first year of diagnosis was 60%, with a relatively few patients regaining volitional voiding by 10 years of follow-up.

CONCLUSION

Among those initially evaluated for urinary retention in the setting of transverse myelitis, intact lower extremity reflexes on physical exam was associated with improved voiding function at most recent follow-up. However, more than half the patients on CIC at initial presentation required CIC at one year of follow-up. Careful, long-term monitoring of voiding status in patients with TM is recommended, even with improvement of neurological status.

Atypical presentation of transverse myelitis in the emergency department

Transverse myelitis (TM) is an inflammatory disorder of the spinal cord characterized by acute onset sensory loss and motor weakness below the level of the lesion. The etiology of the disease is varied, and diagnosis of TM in the Emergency Department (ED) can be difficult owing to the low incidence of the disease, and frequently insidious onset. We report a case of a 59-year-old female who presented to the ED from home with left upper quadrant abdominal pain and flank pain of sudden onset. While in the ED, she experienced left lower extremity weakness and sensory changes that slowly progressed bilaterally, and ultimately was diagnosed with transverse myelitis. Transverse myelitis rarely diagnosed in the ED setting, but it is an important clinical consideration when evaluating ED patients presenting with both pain and progressive neurologic symptoms.

Systematic review of cases of acute myelitis in individuals with COVID-19

Background and purpose

An incremental number of cases of acute transverse myelitis (ATM) in individuals with ongoing or recent coronavirus disease 2019 (COVID‐19) have been reported.

Methods

A systematic review was performed of cases of ATM described in the context of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection by screening both articles published and in preprint.

Results

Twenty cases were identified. There was a slight male predominance (60.0%) and the median age was 56 years. Neurological symptoms first manifested after a mean of 10.3 days from the first onset of classical, mostly respiratory symptoms of COVID‐19. Overall, COVID‐19 severity was relatively mild. Polymerase chain reaction of cerebrospinal fluid for SARS‐CoV‐2 was negative in all 14 cases examined. Cerebrospinal fluid findings reflected an inflammatory process in most instances (77.8%). Aquaporin‐4 and myelin oligodendrocyte protein antibodies in serum (tested in 10 and nine cases, respectively) were negative. On magnetic resonance imaging, the spinal cord lesions spanned a mean of 9.8 vertebral segments, necrotic‐hemorrhagic transformation was present in three cases and two individuals had additional acute motor axonal neuropathy. More than half of the patients received a second immunotherapy regimen. Over a limited follow‐up period of several weeks, 90% of individuals recovered either partially or near fully.

Conclusion

Although causality cannot readily be inferred, it is possible that cases of ATM occur para‐ or post‐infectiously in COVID‐19. All identified reports are anecdotal and case descriptions are heterogeneous. Whether the condition and the observed radiological characteristics are specific to SARS‐CoV‐2 infection needs to be clarified.

Acute flaccid myelitis: long-term outcomes recorded in the CAPTURE study compared with paediatric transverse myelitis

Background

Since 2014, the USA has documented three outbreaks of acute flaccid myelitis (AFM). Unique features and treatment responses of this myelitis variant have not been prospectively studied. This study prospectively measured outcomes in paediatric myelitis patients relative to treatments.

Methods

This was a prospective, multicentre, non-randomised, observational cohort study. The study duration was 5 years and the length of follow-up was 1 year. This study collected data from children and families in North America. Patients were enrolled at academic centres with expertise in myelitis or online via a web portal. Paediatric patients diagnosed with myelitis were eligible for enrolment in the study within 6 months of onset of symptoms. Patients were characterised as transverse myelitis (TM) or the AFM variant based on clinical and radiographic findings.

Results

The cohort of 90 patients included patients with AFM and TM. Of the 51 patients with AFM there was evidence of two clinically relevant patterns. This included a grey matter restricted form of AFM and a cohort with concomitant white matter that could explain lower extremity motor deficits in patients with lesions restricted to the cervical spine. The improvement in deficits with the use of corticosteroids was similar to what was observed in the TM cohort (p=0.97).

Conclusions

Clinicians should consider on a case by case basis the approach to therapy for AFM patients. Prospective controlled studies of long-term outcomes would be useful in this growing patient population.

Lower Urinary Tract Function in Patients with Inflammatory Encephalomyelopathy: Characteristics of Urodynamics, Neurological Deficits and Magnetic Resonance Imaging

OBJECTIVE

To report the clinical data in a large population of patients affected by inflammatory encephalomyelopathy.

MATERIAL AND METHODS

We retrospectively reviewed the medical history, imaging studies and urodynamic findings in a series of 87 consecutive patients with inflammatory encephalomyelopathy. Age at disease onset ranged from 3 to 76 years with an average of 35.4 years. The type of bladder dysfunction, neurological impairment and spinal magnetic resonance imaging were assessed. Upper urinary tract was evaluated. The urological complications and subsequent management were reported.

RESULTS

The mean follow-up was 3.0 years (range from 0.5 to 6.6 yrs). Initial evaluation revealed detrusor overactivity in 53 patients (61.1%), detrusor underactivity in 34 patients (39.1%), detrusor leak point pressure greater than 40 cm water and decreased compliance in 29.9% of patients. At the latest follow-up, a total of 64 patients (73.6%) had persistent bladder dysfunction requiring treatment, mainly presenting as urinary incontinence and incomplete bladder emptying. Around 18.8% patients (13/69) experienced upper urinary tract changes. The location of spinal lesions may correspond with the type of bladder dysfunction. Higher abnormal sensory levels are associated with poor bladder recovery.

CONCLUSION

Persistent bladder dysfunction is common in inflammatory encephalomyelopathy and tend to change with the progression of disease. Evaluation must be instituted at early onset of the disease and ongoing surveillance should be offered through the entire disease process. Management can be tailored individually to the urodynamic findings for optimal preservation of bladder and renal function.

Spinal anesthesia in a patient on monoclonal antibody treatment: a poisoned chalice? A case report

BACKGROUND

Paraplegia is a rare complication of spinal anesthesia.

CASE PRESENTATION

We report a case of a 68-year-old man who developed postoperative paraplegia and hypoesthesia after spinal anesthesia for an otherwise uncomplicated transurethral resection of the prostate. Acute transverse myelitis was diagnosed based on urgent MRI. A prior history of similar though less severe neurological symptoms after obinutuzumab treatment for follicular lymphoma suggested a potential causative role for obinutuzumab, a novel monoclonal antibody that has not been associated with such devastating neurological side effects yet. High-dose steroid treatment partially attenuated the symptoms, but debilitating hypoesthesia and motor deficit remained present 3 months postoperatively.

CONCLUSION

The presented case warrants caution when performing neuraxial anesthesia in patients on monoclonal antibody therapies.

Acute infectious myelopathies

PURPOSE OF REVIEW

The patient who presents with an acute spinal cord syndrome with weakness/paralysis of the limbs presents a diagnostic. Two important syndromes are acute transverse myelitis (ATM) and acute flaccid paralysis (AFP). Both can be caused by a number of infectious and noninfectious causes. Since 2014 there have been outbreaks of acute flaccid myelitis (a subgroup of AFP) in the United States, with a national surveillance program underway. In addition, there have been increasing reports of ATM from new and emerging pathogens, and opportunistic infections in immunocompromised hosts.

RECENT FINDINGS

Infectious causes of ATM or AFP need to be ruled out first. There may be important clues to an infectious cause from epidemiologic risk factors, immune status, international travel, MRI, and laboratory findings. We summarize key features for the more common pathogens in this review. Advances in laboratory testing have improved the diagnostic yield from cerebrospinal fluid, including real-time polymerase chain reaction, metagenomic next-generation sequencing, and advanced antibody detection techniques. These tests still have limitations and require clinical correlation.

SUMMARY

We present a syndromic approach to infectious myelopathies, focusing on clinical patterns that help narrow the diagnostic possibilities.

[Differential diagnostics of autoimmune inflammatory spinal cord diseases]

Myelitis is an acute or subacute inflammatory syndrome of the spinal cord. Myelopathy, often used as a synonym and presenting with similar symptoms in clinical practice, can be caused by numerous, not primarily inflammatory etiologies and might also show a progressive disease course. Within the last decade the spectrum of autoimmune myelitis was significantly broadened as was the spectrum of diagnostic methods. Apart from the characteristic example of multiple sclerosis with short-length myelitis and neuromyelitis optica spectrum disorders with longitudinally extensive transverse myelitis, multiple rare but important differential diagnoses should also be considered. Magnetic resonance imaging and laboratory analyses of serum antibodies and cerebrospinal fluid are the most important diagnostic methods and are fundamental for rapid treatment decisions, subsequently with better prognosis. This article reviews representative diseases within the spectrum of autoimmune spinal cord diseases and their differential diagnoses.

Para-infectious anti-GD2/GD3 IgM myelitis during the Covid-19 pandemic: Case report and literature review

BACKGROUND

Even though SARS-CoV-2 is a predominantly respiratory virus, several reports have described various neurological disorders, from the beginning of the pandemic. The first para-infectious myelitis case was described in Wuhan in February 2020. Nevertheless, data from registries and reviews are scarce.

METHODS

A 40-year-old female with T5-T6 SARS-CoV-2 para-infectious myelitis is reported. A literature review of the published literature on the SARS-CoV-2 and para-infectious myelitis was done. Epidemiological, clinical, laboratory, image, treatment, and outcome data are described.

RESULTS

Particular findings of our case are that Covid-19 was asymptomatic and anti-GD2/GD3 IgM was found. 18 para-infectious myelitis occurred over a wide age range (Beh et al., 2013-67), mean age 50.7±18.6 years, with 10/18 (55.6%) women. Covid-19 involvement was variable from asymptomatic cases to severe Covid-19 resulting in death. The mean time to establish myelitis from the onset of Covid-19 symptoms was 10.3 ±7.8 days (0-24). The most common clinical form was transverse myelitis (14/18 patients, 77.7%) and the most frequent radiological form was longitudinally extensive myelitis (11/17 patients, 64.7%). In CSF mild lymphocytosis (14/16, 87.5%) with low cellularity (40.9±49.7/μL) and elevated proteins (11/16, 77.8%, mean 145.0 mg±159.0/dL) were frequent. Oligoclonal bands were usually negative (7/9, 77.7%) and mirror pattern was found in 2/7 patients (33.3%). SARS-CoV-2 PCR in CSF was negative in 10/10 cases.

CONCLUSION

SARS-CoV-2 can cause myelitis by immune-mediated mechanisms. Clinical-radiological characteristics of Covid-19 para-infectious myelitis were variable and non-specific.

Immune-Mediated Disorders Affecting the Spinal Cord and the Spine

PURPOSE OF REVIEW

To review the most recent advances and provide a description of the most common autoimmune diseases causing myelitis and selective spine disorders. The ultimate goal of this article is to facilitate the prompt recognition of these diseases.

RECENT FINDINGS

The recent discovery of biomarkers such as aquaporin 4 (AQP4) and myelin oligodendrocyte glycoprotein (MOG) antibodies has changed our understanding of autoimmune diseases affecting the spinal cord as well as their treatment and outcomes. Autoimmune neurology is an increasingly evolving field that encompasses a broad spectrum of autoimmune-inflammatory diseases of the central nervous system (CNS) and peripheral nervous system (PNS). Autoimmune disorders of the spinal cord are a heterogeneous group of myelopathies with a broad differential diagnosis and many of them have been recently identified. Prompt recognition of these myelopathies is important as some of them are treatable, which could improve patient outcomes and prevent disability.

Lumbar Puncture: Indications, Challenges and Recent Advances

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Neuromyelitis Optica Presenting as Infectious Meningoencephalitis: Case Report and Literature Review

In this patient-focused review, we present a 34-year-old previously healthy man admitted for fever and headache two weeks after a motor vehicle accident. On admission, his workup was concerning for meningoencephalitis based on elevated cerebrospinal fluid (CSF) white blood cell count and elevated CSF protein. He was admitted for management of meningoencephalitis. During his course, no causative infectious agent was identified despite an extensive workup. He additionally underwent an autoimmune and paraneoplastic workup that was negative. During his hospitalization, he developed acute transverse myelitis manifested by bilateral lower extremity paralysis. After four weeks marked by persistent clinical deterioration, brain biopsy was performed. Pathologic examination was consistent with neuromyelitis optica spectrum disorder (NMOSD). In this case report and literature review, we explore the presentations of NMOSD that mimic an infection. Clinicians should be aware of the possibility of NMOSD masquerading as infectious meningoencephalitis or acute transverse myelitis.

Spinal Cord Infarction: A Single Center Experience and the Usefulness of Evoked Potential as an Early Diagnostic Tool

Background: Spinal cord infarction (SCI) is a rare disease and its early diagnosis is challenging. Here, we described the clinical features and imaging findings of SCI, and assessed the results of evoked potential (EP) studies to elucidate their diagnostic role in the early stage of SCI.

Methods: We retrospectively analyzed 14 patients who had spontaneous SCI. The demographic, neurological, and temporal profiles of the SCI patients were identified. We reviewed the imaging findings and assessed the changes in them over time. To review EP, central motor conduction time (CMCT) and somatosensory evoked potential (SEP) values were obtained. We also enrolled 15 patients with transverse myelitis (TM), and compared the clinical, radiological and electrophysiological features between SCI and TM patients.

Results: The ages of the SCI patients ranged from 54 to 73 years. Nine patients (64.3%) showed nadir deficits within 6 h. The most common type of clinical visit was via the emergency center. Nine patients (64.3%) presented with peri-onset focal pain. The median initial modified Rankin scale score was 3. For 9 patients (64.3%), initial T2 imaging findings were negative, but subsequent diffusion weighed imaging (DWI) showed diffusion restriction. Vertebral body infarction was observed in 5 patients (35.7%). EP data were available for 10 SCI patients. All 8 patients who had their CMCT measured showed abnormalities. Among them, motor evoked potentials were not evoked in 6 patients at all. SEP was measured in 10 patients, and 9 of them showed abnormalities; one of them showed no SEP response. For 5 patients, the EP studies were done prior to DWI, and all the patients showed definite abnormalities. The abnormalities in the EP findings of the SCI patients were more profound than those of the TM patients, even though the duration from the onset to the start of the study was much shorter for SCI patients.

Conclusion: SCI can be diagnosed based on typical clinical manifestations and appropriate imaging studies. Our study also indicates that immediate sensory and motor EP study can have an adjuvant diagnostic role in the hyperacute stage of SCI, and can improve the accuracy of diagnosis.

A retrospective review of the long term clinical outcomes of patients with neurogenic lower urinary tract dysfunction following transverse myelitis

AIMS

Transverse myelitis (TM) is an inflammation of the spinal cord which causes neurological deficit in motor, sensory, and autonomic pathways. Persistent neurogenic lower urinary tract dysfunction (NLUTD) is common even where motor and sensory impairment is recovered. Long term follow-up is required to ensure optimal bladder management and protection of the upper tracts. We describe the clinical outcomes for a cohort of patients with TM who have received neurourological follow-up in a specialist center.

METHODS

A retrospective review of TM patient records was performed. Current pharmaceutical and surgical management, upper tract status, and patient reported symptoms are reported. Changes in urodynamic parameters and bladder emptying technique between current and baseline were analyzed.

RESULTS

Sixty patients with NLUTD following TM were identified. The mean age at onset of NLUTD was 29 years (0-77 years). The mean follow-up was 13 years. 55% of patients were taking antimuscarinic medication, 53% of patients had intradetrusor botulinum toxin injections and 5% had bladder augmentation surgery. Forty-one patients had a baseline and recent urodynamic study which could be compared. Fifty-three of fifty-eight patients with a recent renal ultrasound had normal renal appearance. Four had mild hydronephrosis and one more extensive hydronephrosis.

CONCLUSION

TM can have a persistent effect on lower urinary tract function. There is potential for upper tract damage if bladder management is not optimized. We have demonstrated that in a specialist neurourology unit within a tertiary center, one can provide acceptable long term outcomes following international guidelines.

Frequency and etiology of acute transverse myelitis in Southern Finland

OBJECTIVE

Acute transverse myelitis is a relatively rare, frequently debilitating but potentially treatable emergency. The objective of this study was to evaluate the incidence and etiology of acute transverse myelitis in two major hospital districts in Southern Finland.

METHODS

We identified all patients with acute transverse myelitis admitted to Turku University Hospital and Päijät-Häme Central hospital during nine years. The two hospitals serve a catchment area of 673,000 people in Southern Finland. Acute transverse myelitis was diagnosed according to the 2002 Transverse Myelitis Consortium Working Group. Patient files were reviewed for details of the clinical presentation and disease outcome, for laboratory findings and for neuroimaging. Charts were re-evaluated after an average of 7.7 years for confirmation of the acute transverse myelitis etiology.

RESULTS

In total 63 patients fulfilled the Transverse Myelitis Consortium Working Group diagnostic criteria for acute transverse myelitis. The frequency of the condition was hence 1.04 cases/ 100,000 inhabitants/ year. In the studied cohort, 7/63 (11%) patients had idiopathic transverse myelitis after initial evaluation and in 4/63 (6.3%) patients the idiopathic transverse myelitis remained the final diagnosis after follow-up and re-evaluation. Of the disease-associated myelitis cases MS or clinically isolated syndrome was the largest group, explaining 41% of all myelitis cases. The mean follow-up time before a patient was diagnosed with MS was 1.7 ± 2.2 years. Other etiologies included acute disseminated encephalomyelitis (ADEM), neurosarcoidosis, neuromyelitis optica (NMO), systemic autoimmune diseases and infectious diseases.

CONCLUSIONS

In more than half of the acute transverse myelitis cases the final diagnosis is other than MS. Careful diagnostic work-up is needed for correct early treatment and best long-term outcome.

Spinal manifestations of CLN1 disease start during the early postnatal period

Aim

To understand the progression of CLN1 disease and develop effective therapies we need to characterize early sites of pathology. Therefore, we performed a comprehensive evaluation of the nature and timing of early CLN1 disease pathology in the spinal cord, which appears especially vulnerable, and how this may affect behaviour.

Methods

We measured the spinal volume and neuronal number, and quantified glial activation, lymphocyte infiltration and oligodendrocyte maturation, as well as cytokine profile analysis during the early stages of pathology in Ppt1‐deficient (Ppt1^−/−) mouse spinal cords. We then performed quantitative gait analysis and open‐field behaviour tests to investigate the behavioural correlates during this period.

Results

We detected significant microglial activation in Ppt1^−/− spinal cords at 1 month. This was followed by astrocytosis, selective interneuron loss, altered spinal volumes and oligodendrocyte maturation at 2 months, before significant storage material accumulation and lymphocyte infiltration at 3 months. The same time course was apparent for inflammatory cytokine expression that was altered as early as one month. There was a transient early period at 2 months when Ppt1^−/− mice had a significantly altered gait that resembles the presentation in children with CLN1 disease. This occurred before an anticipated decline in overall locomotor performance across all ages.

Conclusion

These data reveal disease onset 2 months (25% of life‐span) earlier than expected, while spinal maturation is still ongoing. Our multi‐disciplinary data provide new insights into the spatio‐temporal staging of CLN1 pathogenesis during ongoing postnatal maturation, and highlight the need to deliver therapies during the presymptomatic period.

[Transverse myelitis syndrom as a result of neuromyelitis optica spectrum disorders, systemic lupus erythematosus and myasthenia gravis combination]

Neuromyelitis optica spectrum disorders (NMOSD) - autoimmune condition characterized by an inflammatory lesions mainly of the spinal cord with the development of longitudinally extensive transverse myelitis (LETM) and/or involvement of the optic nerve with the development of usually bilateral optical neuritis (ON). In recent years, there has been increased awareness that NMOSD can be combined with other autoimmune diseases, including myasthenia gravis (MG), systemic lupus erythematosus (SLE) et al. The simultaneous presence of several autoimmune diseases in one patient can adversely affect the course of each of the diseases, causing the so-called mutual burden or «overlap syndrome». In this article, we describe our own clinical observation of a 51-year-old woman of European origin who developed acute relapsing TM seropositive for AQP4-IgG, by 23 years after the diagnosis of generalized MG seropositive for antibodies to acetylcholine receptors (AChR-Ab) and the occurrence of SLE, criterially confirmed, several months after the initial TM attack. During the fourth TM attack, partial positive dynamics was achieved only against the background of the combined use of intravenous methylprednisolone (pulse therapy), high-volume plasma exchange, rituximab and cyclophosphamide. The NMOSD is a rare disease leading to severe disability. In patients with MG, when symptoms of damage to the central nervous system appear, an analysis should be performed for AQP4-IgG and possibly for antibodies to myelin glycoprotein of oligodendrocytes (MOG-Ab), as well as markers characteristic of systemic connective tissue diseases (SCTD). In patients with STDD, when symptoms of involvement nervous systemappear, testing for AQP4-IgG (and, if necessary, for MOG-Ab) should be performed to exclude NMOSD, as well as AChR-Ab (and, if necessary, antibodies against muscle specific kinase (MuSK-Ab)) to exclude MG.

COVID-19-associated acute transverse myelitis: a rare entity

SARS-CoV-2 has wreaked havoc globally and has claimed innumerable lives all over the world. Apart from the characteristic respiratory illness, this disease has been associated with florid extrapulmonary manifestations and complications. A 59-year-old female healthcare worker presented with features of acute-onset non-compressive myelopathy with a sensory level at T10 segment along with high-grade fever for 4 days. MRI of dorsal spine was suggestive of myelitis at T7 vertebral level. She was initiated on injectable steroids and did show some initial signs of recovery. A day later, she developed an acute-onset respiratory failure but could not be revived despite our best efforts. Her nasopharyngeal and oropharyngeal swab turned out to be positive for SARS-CoV-2 reverse transcriptase polymerase chain reaction (RT-PCR). We hereby report a case of acute transverse myelitis with COVID-19 as a probable aetiology.