Cytomegalovirus-associated transverse myelitis in a non-immunocompromised patient

[Cytomegalovirus associated myelitis in a non-immunocompromised adult due to initial cytomegalovirus infection]

The patient was a 30-year-old man who developed muscle weakness in both lower extremities, sensory deficits below the fourth thoracic spinal cord level, and bladder rectal dysfunction owing to cytomegalovirus (CMV) associated myelitis. His blood tests showed mononucleosis, hepatic dysfunction, and the presence of serum CMV-IgM antibodies, and T₂-weighted imaging on MRI displayed a continuous high signal on the ventral side of the spinal cord. Although his medical history and laboratory tests did not indicate that he was immunocompromised, we speculated he had CMV-associated myelitis. As the first infection with CMV in a non-immunocompromised adult can result in mononucleosis, we considered that this patient developed myelitis after mononucleosis caused by CMV infection for the first time. CMV-associated myelitis in non-immunocompromised individuals is rare. In general, CMV infections are common in immunosuppressed individuals. However, in Japan, adults with CMV antibodies have recently been decreasing, and hence CMV infections in non-immunocompromised adults are expected to increase in the future.

Cytomegalovirus associated longitudinally extensive transverse myelitis and acute hepatitis in an immunocompetent adult

Cytomegalovirus can cause severe disease in immunocompromised patients including encephalomyelitis, hepatitis, pneumonitis, colitis and retinitis. CMV induced myelitis and hepatitis are rare in immunocompetent patients. Following a thorough search on the literature using pubmed, there were only 10 well documented CMV-induced transverse myelitis cases reported worldwide. We report a healthy young male who developed longitudinal extensive transverse myelitis and acute hepatitis secondary to CMV infection. Our case is different from the other cases as our patient had concurrent acute hepatitis and received plasma exchange therapy (PLEX) in addition to pulsed steroids and antivirals. The patient recovered well and had an excellent outcome.

Cytomegalovirus-associated encephalomyelitis in an immunocompetent adult: a two-stage attack of direct viral and delayed immune-mediated invasions. case report

Background

It is clinically rare to find cytomegalovirus (CMV)-associated encephalomyelitis in immunocompetent adults. Here, we present the case of an adult patient who developed acute transverse myelitis that was followed by immune-mediated disseminated encephalomyelitis.

Case presentation

A 38-year-old man developed acute paraplegia with paresthesia below the level of the T7-8 dermatome. Both brain and spinal cord MRIs performed at admission appeared normal. Corticosteroid therapy was initiated, with the later addition of high-dose intravenous immunoglobulins. After polymerase chain reaction analysis indicated the presence of CMV DNA in his cerebrospinal fluid (CSF), anti-viral therapy was added. Forty days after symptom onset, despite an initial positive response to this therapy, he developed dysarthria and truncal ataxia. Repeated magnetic resonance imaging scans demonstrated progressively expanding lesions involving not only the spinal cord but also the cerebral white matter, suggestive of extensive immune-mediated demyelination involving the central nervous system (CNS), as is observed in acute disseminated encephalomyelitis (ADEM).

Conclusion

This case report underscores the importance of careful patient observation following the initial diagnosis of a CMV-associated CNS infection, such as transverse myelitis, on the possibility that post-infectious ADEM may appear.

Cytomegalovirus-associated transverse myelitis: a review of nine well-documented cases

Abstract Cytomegalovirus-associated transverse myelitis is a rare disease. We found 12 cases in the medical literature, 8 of which met our criteria for being well documented. Our aim was to review this clinical entity using information from our own clinical experience as well as published cases.

Idiopathic transverse myelitis and neuromyelitis optica: clinical profiles, pathophysiology and therapeutic choices

Transverse myelitis is a focal inflammatory disorder of the spinal cord which may arise due to different etiologies. Transverse myelitis may be idiopathic or related/secondary to other diseases including infections, connective tissue disorders and other autoimmune diseases. It may be also associated with optic neuritis (neuromyelitis optica), which may precede transverse myelitis. In this manuscript we review the pathophysiology of different types of transverse myelitis and neuromyelitis optica and discuss diagnostic criteria for idiopathic transverse myelitis and risk of development of multiple sclerosis after an episode of transverse myelitis. We also discuss treatment options including corticosteroids, immunosuppressives and monoclonal antibodies, plasma exchange and intravenous immunoglobulins.

Cytomegalovirus associated transverse myelitis in an immunocompetent host with DNA detection in cerebrospinal fluid; a case report

Background

Cytomegalovirus associated transverse myelitis among immunocompetent adults has been rarely reported. We report a patient presenting with clinical myelitis followed by previously unreported finding of cytomegalovirus deoxyribonucleic acid in cerebrospinal fluid.

Case report

A forty year old immunocompetent male presented with acute onset progressive bilateral lower limb weakness. His spinal magnetic resonance imaging findings, cerebrospinal fluid analysis and clinical picture were compatible with transverse myelitis. Polymerase chain reaction of the cerebrospinal fluid for cytomegalovirus was positive while other infectious agents were not detected by serology or polymerase chain reaction. He was treated with intravenous ganciclovir with partial clinical response.

Conclusion

Viral genome detection in the cerebrospinal fluid was performed but negative in five out of ten reported cases of cytomegalovirus associated transverse myelitis in the immunocompetent host. In previous cases the inability to isolate the virus in cerebrospinal fluid was considered favouring an immunological mechanism leading to pathogenesis rather than direct viral toxicity but this case is against that theory. This case highlights the fact that Cytomegalovirus should be considered as an aetiological agent in patients with transverse myelitis and that the virus may cause serious infections in immunocompetent host. Therefore this report is of importance to neurologists and physicians in general.

Central nervous system infections of herpesvirus family

Herpesviruses are one of the most common groups of pathogens causing central nervous system infections in humans. They mostly cause encephalitis, meningitis, or myelitis in immunocompetent and immunocompromised patients. Children, adults, and the elderly can all be affected. Although contrast-enhanced CT is more widely used for diagnosis, contrast-enhanced MR imaging combined with diffusion-weighted imaging is superior to CT in the detection of early changes and the real extent of the disease, and in assessing prognosis and monitoring response to antiviral treatment. More sophisticated techniques, such as MR spectroscopy and perfusion imaging, can aid in the differential diagnosis of herpesvirus infections from other tumoral, demyelinating, and ischemic processes.

The expanding spectrum of herpesvirus infections of the nervous system

Herpesviruses cause various acute, subacute, and chronic disorders of the central (CNS) and peripheral (PNS) nervous systems in adults and children. Both immunocompetent and immunocompromised individuals may be affected. Zoster (shingles), a result of reactivation of varicella zoster virus (VZV), is the most frequent neurologic complication. Other neurological complications include encephalitis produced by type I herpes simplex virus (HSV-1), and less frequently HSV-2, as well as by VZV and cytomegalovirus (CMV). Acute meningitis is seen with VZV and HSV-2, and benign recurrent meningitis with HSV-2. Combinations of meningitis/ encephalitis and myelitis/radiculitis are associated with Epstein Barr Virus (EBV); myelitis with VZV, CMV, EBV, and HSV-2; and ventriculitis/encephalitis with VZV and CMV. Brainstem encephalitis due to HSV and VZV, and polymyeloradiculitis due to CMV are well documented. HHV-6 produces childhood exanthem subitum (roseola) and febrile convulsions. Immunocompetent and immunocompromised hosts manifest different incidences and patterns of herpesvirus infections. For example, stroke due to VZV-mediated large vessel disease (herpes zoster ophthalmicus) occurs predominantly in immunocompetent hosts, while small vessel disease (leukoencephalitis) and ventriculitis develop almost exclusively in immunocompromised patients. EBV-associated primary CNS lymphomas also are restricted to immunosuppressed individuals. Recent large CSF PCR studies have shown that VZV, EBV, and CMV more frequently produce meningitis, encephalitis, or encephalopathy in immunocompetent hosts than was formerly realized. We review herpesvirus infections of the nervous system and illustrate the expanding spectrum of disease by including examples of a 75-year-old male on steroid treatment for chronic lung disease with fatal HSV-2 meningitis and an 81-year-old male with myasthenia gravis, long-term azathioprine use, and an EBV-associated primary CNS lymphoma.

Cytomegalovirus-associated acute transverse myelitis in immunocompetent adults

We report a case of transverse myelitis as a complication of acute cytomegalovirus (CMV) infection in immunocompetent patients; and review the literature on the entity. Primary CMV infection was documented by CMV antigenemia and high serum titers of CMV IgM and IgG antibodies. Cerebrospinal fluid (CSF) pleocytosis indicated central nervous system inflammation; CSF polymerase chain reaction (PCR) for CMV, however, was negative. The results of magnetic resonance imaging of the myelon were normal. Although CMV-associated transverse myelitis has been well described in HIV-positive individuals, but is very rare in immunocompetent individuals. It remains unclear whether the neuronal damage is immune mediated or due to a cytotoxic effect of viral infection. The outcome is mainly favorable.

CNS manifestations of cytomegalovirus infections: diagnosis and treatment

Cytomegalovirus (CMV) infection of the CNS occurs most commonly in patients with severe immunosuppression such as those with advanced HIV infection (i.e. AIDS) or those who have undergone bone marrow or solid organ transplantation. Immunocompetent patients are affected very rarely. The infection of the CNS may affect the brain (diffuse encephalitis, ventriculoencephalitis, cerebral mass lesions) or the spinal cord (transverse myelitis, polyradiculomyelitis). Diagnosis is very difficult and should be based on clinical presentation, results of imaging and virological markers. The most specific diagnostic tool is the detection of CMV DNA by polymerase chain reaction in the CSF. Treatment should be initiated promptly if CMV infection is suspected. Antiviral therapy consists of intravenous ganciclovir, intravenous foscarnet or a combination of both. Cidofovir is the treatment of second choice. Patients who experience clinical improvement or stabilisation during induction therapy should be given maintenance therapy. After immune reconstitution (in HIV-positive patients) or discontinuation of immunosuppressive therapy (in transplant recipients), maintenance therapy may be stopped. Despite therapy, the prognosis for long-term survival is very poor, especially in patients with AIDS.

Immunopathogenesis of acute transverse myelitis

Acute transverse myelitis is a group of disorders characterized by focal inflammation of the spinal cord and resultant neural injury. Acute transverse myelitis may be an isolated entity or may occur in the context of multifocal or even multisystemic disease. It is clear that the pathological substrate--injury and dysfunction of neural cells within the spinal cord--may be caused by a variety of immunological mechanisms. For example, in acute transverse myelitis associated with systemic disease (i.e. systemic lupus erythematosus or sarcoidosis), a vasculitic or granulomatous process can often be identified. In idiopathic acute transverse myelitis, there is an intraparenchymal or perivascular cellular influx into the spinal cord, resulting in the breakdown of the blood-brain barrier and variable demyelination and neuronal injury. There are several critical questions that must be answered before we truly understand acute transverse myelitis: (1) What are the various triggers for the inflammatory process that induces neural injury in the spinal cord? (2) What are the cellular and humoral factors that induce this neural injury? and (3) Is there a way to modulate the inflammatory response in order to improve patient outcome? Although much remains to be elucidated about the causes of acute transverse myelitis, tantalizing clues as to the potential immunopathogenic mechanisms in acute transverse myelitis and related inflammatory disorders of the spinal cord have recently emerged. It is the purpose of this review to illustrate recent discoveries that shed light on this topic, relying when necessary on data from related diseases such as acute disseminated encephalomyelitis, Guillain-Barré syndrome and neuromyelitis optica. Developing a further understanding of how the immune system induces neural injury will depend upon confirmation and extension of these findings and will require multicenter collaborative efforts.

Cytomegalovirus-associated transverse myelitis in a non-immunocompromised patient

DESIGN

Single case report.

OBJECTIVE

To report a rare case of cytomegalovirus (CMV)-associated transverse myelitis (TM) in the immunocompetent host.

SETTINGS

Collaboration between a Neurology and Radiology University Department in Greece and a Molecular Virology Department in Cyprus.

PATIENT

A 16-year-old male student developed an acute febrile illness followed shortly by TM, that resulted in paraplegia over 24 h. Rapid clinical improvement was followed by complete recovery in 2 months. Extensive laboratory work-up excluded other possible causes of TM and showed no evidence of an immunocompromised state. Antiviral serological data, identification of the viral genome by polymerase chain reaction and serial spinal cord magnetic resonance imaging findings, supported the diagnosis of CMV-associated TM in a non-immunocompromised patient.

CONCLUSIONS

Our case further indicates that CMV infection should be included in the differential diagnosis of TM of uncertain etiology, in the immunocompetent patient. Clinical, immunological and neuroimaging findings indicate that post-infectious immune mediated inflammation, seems the most probable pathogenetic mechanism in this case.

Myelitis

Acute transverse myelitis (ATM) with moderate symptomatology and smaller multiple magnetic resonance imaging lesions is often caused by multiple sclerosis. Severe ATM with extensive magnetic resonance imaging lesions with or without associated meningitis often has a viral cause, particularly in the younger age groups, whereas vascular disorders may prevail among older patients. Previously, one had to rely on indirect evidence such as viral serology or viral identification in throat washings to confirm a diagnosis of myelitis. Thus, mycoplasma myelitis may occur coincident with a mycoplasma pneumonia. Viral myelitis is now often diagnosed by specific polymerase chain reaction of the cerebrospinal fluid, for echovirus, Coxsackie virus, mumps virus, herpes simplex virus or varicella-zoster virus, but an autoimmune component may still be important. An anterior horn syndrome may be produced by the tick-borne encephalomyelitis virus. Severe ATM may also be a postinfectious or postvaccinal disorder [i.e. a partial acute disseminated encephalomyelitis (ADEM)]. Neuromyelitis optica, a combination of severe myelitis and optic neuritis, is often a manifestation of ADEM or systemic lupus erythematosus. Many of these disorders are potentially treatable with specific antiviral agents or immunosuppression. 'Idiopathic' ATM is probably a consequence of inadequate examination and follow up. The differential diagnoses-viral myelitis, multiple sclerosis, ADEM, neuromyelitis optica, spinal arteriovenous malformation and arteritis-should be considered and are usually identified by a rapid diagnostic work-up, leaving few ATM cases undiagnosed.