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Singh D, deFisser G, Samuel S, Chennu NT, Polhemus L, Rodriguez W, Kafaie J. Transverse Myelitis: A Case-Based Discussion of Infectious Etiologies. Cureus 2024; 16:e63079. [PMID: 39055452 PMCID: PMC11269968 DOI: 10.7759/cureus.63079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2024] [Indexed: 07/27/2024] Open
Abstract
Transverse myelitis (TM) is a frequently encountered inpatient neurological condition, usually with a broad differential of etiologies narrowed down by detailed history, temporal profile of symptom evolution, and pertinent diagnostic studies. We report a rare case of a 39-year-old man who presented with subacute onset of headaches and confusion, and three days later developed quadriplegia and areflexia. He was diagnosed with acute longitudinally extensive transverse myelitis (LETM) related to Epstein-Barr virus (EBV) superimposed on an initial presentation of streptococcal meningitis. As both etiologies are under-reported, we compare our case to the few similar cases in the literature to guide discussion of the clinical and radiologic findings of parainfectious TM related to EBV and streptococcal meningitis. Readers will have the challenge of attributing our patient's myelitis to one of these parainfectious sources and are encouraged to evaluate for rare infectious etiologies in acute settings.
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Affiliation(s)
- Divya Singh
- Neurology, Saint Louis University School of Medicine, St. Louis, USA
| | - Gavin deFisser
- Neurology, Saint Louis University School of Medicine, St. Louis, USA
| | - Sandra Samuel
- Neurology, Saint Louis University School of Medicine, St. Louis, USA
| | - Navreet T Chennu
- Neurology, Saint Louis University School of Medicine, St. Louis, USA
| | - Laura Polhemus
- Neurology, Saint Louis University School of Medicine, St. Louis, USA
| | - Wilson Rodriguez
- Neurology, Saint Louis University School of Medicine, St. Louis, USA
| | - Jafar Kafaie
- Neurology, Saint Louis University Hospital, St. Louis, USA
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2
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Labib A, Burke O, Nichols A, Maderal AD. Approach to diagnosis, evaluation, and treatment of generalized and nonlocal dysesthesia: A review. J Am Acad Dermatol 2023; 89:1192-1200. [PMID: 37517675 DOI: 10.1016/j.jaad.2023.06.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 08/01/2023]
Abstract
Dysesthesia is an abnormal sensation in the skin that occurs in the absence of any extraordinary stimulus or other primary cutaneous disorders, excluding any delusions or tactile hallucinations. Clinicians have characterized dysesthesias to include sensations such as burning, tingling, pruritus, allodynia, hyperesthesia, or anesthesia. The etiology and pathogenesis of various generalized dysesthesias is largely unknown, though many dysesthesias have been associated with systemic pathologies including malignancy, infection, autoimmune disorders, and neuropathies. Dermatologists are often the first-line clinicians for patients presenting with such cutaneous findings, thus it is crucial for these physicians to be able to methodically work-up generalized dysesthesias to build a working differential diagnosis, follow up with key labs and/or imaging, and offer patients evidence-based treatment to relieve their symptoms. This broad literature review is an attempt to centralize key studies, cases, and series to help guide dermatologists in their assessment and evaluation of complaints of abnormal cutaneous sensations.
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Affiliation(s)
- Angelina Labib
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Olivia Burke
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Anna Nichols
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Andrea D Maderal
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida.
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3
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Harrold GK, Ali AS, Berkowitz AL, Bhattacharyya S. Clinical Features and Diagnosis of Intramedullary Spinal Cord Abscess in Adults: A Systematic Review. Neurology 2023; 101:e836-e844. [PMID: 37400243 PMCID: PMC10449440 DOI: 10.1212/wnl.0000000000207515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 04/25/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Intramedullary spinal cord abscess (ISCA) was described 200 years ago but remains poorly understood and is often mistaken for immune-mediated or neoplastic processes. We present a systematic review of ISCA in adults, describing the clinical presentation, diagnostic features, treatment strategies, and outcomes. METHODS Database searches for intramedullary abscess were performed on April 15, 2019, and repeated on February 9, 2022, using PubMed and EMBASE with 2 unpublished cases also included. Publications were independently reviewed for inclusion by 2 authors followed by adjudication. Data were abstracted using an online form and then analyzed for predictors of disability. RESULTS A total of 202 cases were included (median age 45 years [interquartile range 31-58]; 70% male). Thirty-one percent of those affected had no identified predisposing condition. The most common symptom was weakness (97%), and the median symptom duration before presentation was 10 days (interquartile range 5-42). An MRI showed restricted diffusion in 100% of 8 cases where performed and enhancement in 99% of 153 cases where performed. The most common organisms were Mycobacterium tuberculosis (29%), Streptococcus sp. (13%), and Staphylococcus sp. (10%). All patients received antimicrobial therapy; surgical drainage was performed in 65%. At follow-up (median 6 months), 12% had died, 69% were ambulatory, and 77% had improved compared with clinical nadir. Of those who underwent operative intervention, surgery within 24 hours of diagnosis was associated with an increased likelihood of being ambulatory at follow-up compared with surgery after 24 hours (odds ratio 4.44; 95% CI 1.26-15.61; p = 0.020). DISCUSSION ISCA is important to consider in any patient presenting with acute-to-subacute, progressive myelopathy. Immunocompromise and typical signs of infection (e.g., fever) are often absent. Diffusion restriction and gadolinium enhancement on MRI seem to be sensitive. Antimicrobial therapy with surgical drainage is the most common therapeutic approach, but morbidity remains substantial. If performed, urgent surgery may be more beneficial.
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Affiliation(s)
- G Kyle Harrold
- From the Department of Neurology (G.K.H., A.S.A., S.B.), Brigham and Women's Hospital, Boston, MA; and Department of Neurology (A.L.B.), University of California, San Francisco, CA.
| | - Ahya Sajawal Ali
- From the Department of Neurology (G.K.H., A.S.A., S.B.), Brigham and Women's Hospital, Boston, MA; and Department of Neurology (A.L.B.), University of California, San Francisco, CA
| | - Aaron L Berkowitz
- From the Department of Neurology (G.K.H., A.S.A., S.B.), Brigham and Women's Hospital, Boston, MA; and Department of Neurology (A.L.B.), University of California, San Francisco, CA
| | - Shamik Bhattacharyya
- From the Department of Neurology (G.K.H., A.S.A., S.B.), Brigham and Women's Hospital, Boston, MA; and Department of Neurology (A.L.B.), University of California, San Francisco, CA
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Chinnappan J, Parajuli A, Marcus H, Bachuwa G. Constipation in transverse myelitis. BMJ Case Rep 2023; 16:16/3/e254409. [PMID: 36878618 PMCID: PMC9990615 DOI: 10.1136/bcr-2022-254409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Transverse myelitis is an extremely rare neuroinflammatory disorder. About half of the affected patients develop paraplegia associated with urinary and bowel dysfunction. The bowel dysfunction is thought to be benign and is usually managed with dietary management and laxatives. We report a case of a man in his 60s presenting with transverse myelitis and the acute disease course complicated with treatment refractory intestinal dysfunction resulting in intestinal perforation, eventually leading to his death. Thus, this case helps us weigh the fact that intestinal dysfunction in the case of transverse myelitis is not always benign but can lead to deadly outcomes as well.
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Affiliation(s)
- Justine Chinnappan
- Department of Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
| | - Abinash Parajuli
- Department of Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
| | - Huda Marcus
- Department of Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
| | - Ghassan Bachuwa
- Department of Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
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Mathew E, Williamson J, Mamo L, Dickerman R. Transverse myelitis after Johnson & Johnson COVID-19 vaccine: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22244. [PMID: 36681970 PMCID: PMC9745584 DOI: 10.3171/case22244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transverse myelitis is a rare neurological occurrence with varied presentation. Imaging is necessary to properly diagnose this condition; however, identifying the cause of this condition may often be difficult. OBSERVATIONS An otherwise healthy patient presented to the clinic with peculiar neurological symptoms without an obvious underlying cause. Imaging evidenced no significant structural defects but did lead to discovery of cord enhancement compatible with a diagnosis of transverse myelitis. Corticosteroid treatment was initiated rapidly to address this pathology, and the patient recovered without deficits. To identify the underlying cause, patient medical history was reviewed thoroughly and compared with existing literature. Previous tuberculosis infection could be a less likely cause of the neurological symptoms. However, recent vaccination with the Johnson & Johnson coronavirus disease 2019 (COVID-19) vaccine could be a more likely cause of the transverse myelitis, which has been rarely reported. LESSONS Transverse myelitis after COVID-19 infection has been an escalating phenomenon. However, transverse myelitis after COVID-19 vaccination is a rare occurrence that is also on the rise. Given the increased rates of vaccination, transverse myelitis should not be overlooked as a potential pathology, due to the severity of neurological impairment if this condition is not treated rapidly.
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Affiliation(s)
- Ezek Mathew
- University of North Texas Health Science Center, Fort Worth, Texas; and
| | - Julie Williamson
- Department of Neurosurgery, The Medical City of Frisco, Frisco, Texas
| | - Lois Mamo
- Department of Neurosurgery, The Medical City of Frisco, Frisco, Texas
| | - Rob Dickerman
- Department of Neurosurgery, The Medical City of Frisco, Frisco, Texas
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Nontraumatic Spinal Cord Injury: Epidemiology, Etiology and Management. J Pers Med 2022; 12:jpm12111872. [PMID: 36579590 PMCID: PMC9694799 DOI: 10.3390/jpm12111872] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/02/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
The spinal cord is a conduit within the central nervous system (CNS) that provides ongoing communication between the brain and the rest of the body, conveying complex sensory and motor information necessary for safety, movement, reflexes, and optimization of autonomic function. After a traumatic spinal cord injury (SCI), supraspinal influences on the peripheral nervous system and autonomic nervous system (ANS) are disrupted, leading to spastic paralysis, sympathetic blunting, and parasympathetic dominance, resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions, and uncontrolled bowel, bladder, and sexual dysfunction. This article outlines the pathophysiology of the less reported nontraumatic SCI (NTSCI), its classification, its influence on sensory/motor function, and introduces the probable comorbidities associated with SCI that will be discussed in more detail in the accompanying manuscripts of this special issue. Finally, management strategies for NTSCI will be provided.
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Mahroum N, Lavine N, Ohayon A, Seida R, Alwani A, Alrais M, Zoubi M, Bragazzi NL. COVID-19 Vaccination and the Rate of Immune and Autoimmune Adverse Events Following Immunization: Insights From a Narrative Literature Review. Front Immunol 2022; 13:872683. [PMID: 35865539 PMCID: PMC9294236 DOI: 10.3389/fimmu.2022.872683] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/30/2022] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Naim Mahroum
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
- Zabludowicz Center for autoimmune diseases, Sheba Medical Center, Ramat-Gan, Israel
| | - Noy Lavine
- Zabludowicz Center for autoimmune diseases, Sheba Medical Center, Ramat-Gan, Israel
- St. George School of Medicine, University of London, London, United Kingdom
| | - Aviran Ohayon
- Zabludowicz Center for autoimmune diseases, Sheba Medical Center, Ramat-Gan, Israel
- St. George School of Medicine, University of London, London, United Kingdom
| | - Ravend Seida
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Abdulkarim Alwani
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Mahmoud Alrais
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Magdi Zoubi
- Zabludowicz Center for autoimmune diseases, Sheba Medical Center, Ramat-Gan, Israel
| | - Nicola Luigi Bragazzi
- Laboratory for Industrial and Applied Mathematics (LIAM), Department of Mathematics and Statistics, York University, Toronto, ON, Canada
- *Correspondence: Nicola Luigi Bragazzi,
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8
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Barman A, Sahoo J, Viswanath A, Roy SS, Swarnakar R, Bhattacharjee S. Clinical Features, Laboratory, and Radiological Findings of Patients With Acute Inflammatory Myelopathy After COVID-19 Infection: A Narrative Review. Am J Phys Med Rehabil 2021; 100:919-939. [PMID: 34347629 PMCID: PMC8436817 DOI: 10.1097/phm.0000000000001857] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT The objective of this review was to analyze the existing data on acute inflammatory myelopathies associated with coronavirus disease 2019 infection, which were reported globally in 2020. PubMed, CENTRAL, MEDLINE, and online publication databases were searched. Thirty-three acute inflammatory myelopathy cases (among them, seven cases had associated brain lesions) associated with coronavirus disease 2019 infection were reported. Demyelinating change was seen in cervical and thoracic regions (27.3% each, separately). Simultaneous involvement of both regions, cervical and thoracic, was seen in 45.4% of the patients. Most acute inflammatory myelopathy disorders reported sensory motor and bowel bladder dysfunctions. On cerebrospinal fluid analysis, pleocytosis and increased protein were reported in 56.7% and 76.7% of the patients, respectively. Cerebrospinal fluid severe acute respiratory syndrome coronavirus 2 reverse transcriptase-polymerase chain reaction was positive in five patients. On T2-weighted imaging, longitudinally extensive transverse myelitis and short-segment demyelinating lesions were reported in 76% and 21%, respectively. Among the patients with longitudinally extensive transverse myelitis, 61% reported "moderate to significant" improvement and 26% demonstrated "no improvement" in the motor function of lower limbs. Demyelinating changes in the entire spinal cord were observed in three patients. Most of the patients with acute inflammatory myelopathy (including brain lesions) were treated with methylprednisolone (81.8%) and plasma-exchange therapy (42.4%). An early treatment, especially with intravenous methylprednisolone with or without immunoglobulin and plasma-exchange therapy, helped improve motor recovery in the patients with acute inflammatory myelopathy associated with coronavirus disease 2019.
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9
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Hwang M, Flanagan A, Graf A, Kruger KM, Scullion N, Tayne S, Altiok H. Gait Characteristics in Youth With Transverse Myelitis. Top Spinal Cord Inj Rehabil 2021; 27:38-48. [PMID: 34456545 DOI: 10.46292/sci20-00048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Transverse myelitis (TM) in childhood is a rare disorder characterized by the presence of spinal cord inflammation. Gait difficulty in children with TM is common; however, there is a paucity of literature regarding quantitative assessment of gait in children and adolescents with TM. Objectives To characterize gait patterns in a cohort of ambulatory children with TM and age-matched, typically developing peers in order to better understand the functional mobility of patients diagnosed with childhood TM. Methods This was a retrospective study of 26 ambulatory pediatric patients with a confirmed diagnosis of TM who had undergone three-dimensional, instrumented gait analysis (3D-IGA) at 3 years of age or older. A group of 38 typically developing children served as a control group. Results Gait in children with TM was characterized by moderate kinematic deviations as measured by the Gait Deviation Index (GDI) and a crouched gait pattern (p < .001), increased anterior pelvic tilt (p < .001), decreased motion at the knees (p < .001), and a wider base of support (foot progression angle, p < .001). The TM group had a slower walking speed (p < .001), shorter strides (p < .001), and an increased stance phase compared to controls. Conclusion Our study results showed moderate kinematic deviations quantified by the GDI. Overall, the gait pattern in the TM population tested had greater hip and knee flexion with wider foot progression angle. Identification of gait characteristics in children with TM is the first step in predicting changes in gait pattern as they mature over time, which may ultimately allow for targeted intervention to maintain their ambulatory function.
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Affiliation(s)
- Miriam Hwang
- Shriners Hospitals for Children, Chicago, Illinois
| | - Ann Flanagan
- Shriners Hospitals for Children, Chicago, Illinois
| | - Adam Graf
- Shriners Hospitals for Children, Chicago, Illinois
| | - Karen M Kruger
- Shriners Hospitals for Children, Chicago, Illinois.,Marquette University, Milwaukee, Wisconsin
| | | | | | - Haluk Altiok
- Shriners Hospitals for Children, Chicago, Illinois
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10
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Sebastian AP, Basu A, Mitta N, Benjamin D. Transverse myelitis caused by varicella-zoster. BMJ Case Rep 2021; 14:e238078. [PMID: 34462272 PMCID: PMC8407226 DOI: 10.1136/bcr-2020-238078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2021] [Indexed: 11/03/2022] Open
Abstract
Transverse myelitis is a rare neurological complication seen with varicella-zoster virus (VZV) infection, which is common among immunocompromised hosts. It can occur during the primary VZV infection or reactivation of latent infection. It is a complication that requires prompt diagnosis and treatment. The present case is that of a 28-year-old immunocompetent man, who presented with fever, rash and acute-onset spastic paraparesis with bladder involvement. Causes such as herpes simplex 1 and 2, cytomegalovirus, enterovirus and Epstein-Barr virus infection were ruled out. On evaluation, he was diagnosed with acute primary disseminated VZV infection with parainfectious transverse myelitis, based on positive cerebrospinal fluid multiplex PCR (PCR) and serum VZV IgM antibodies. He was treated with intravenous acyclovir and steroids, with which he improved significantly.
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Affiliation(s)
| | - Arini Basu
- Internal Medicine, Bangalore Baptist Hospital, Bangalore, Karnataka, India
| | - Nandini Mitta
- Department of Neurology, Bangalore Baptist Hospital, Bangalore, Karnataka, India
| | - Dominic Benjamin
- Internal Medicine, Bangalore Baptist Hospital, Bangalore, Karnataka, India
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11
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Lee G. Acute longitudinal extensive transverse myelitis secondary to asymptomatic SARS-CoV-2 infection. BMJ Case Rep 2021; 14:14/7/e244687. [PMID: 34226258 PMCID: PMC8258563 DOI: 10.1136/bcr-2021-244687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A 35-year-old woman, 6 months post partum, presented with acute onset back pain at the T8 level progressing to bilateral lower limb weakness and sensory loss with urinary retention and constipation. This patient had a pre-existing inflammatory disease, having recently developed ulcerative colitis antenatally. Five days prior to admission, she had tested positive asymptomatically on a SARS-CoV-2 reverse-transcriptase PCR nasopharyngeal swab. The positive swab result was confirmed on admission. Clinical examination revealed bilaterally exaggerated knee reflexes, lower limb weakness and positive Babinski’s sign. Sensation was impaired at L4 and L5 dermatomes and absent at S1 and S2. MRI findings suggested longitudinal extensive transverse myelitis, with multiple regions of patchy hyperintensity seen in the thoracic region of the spinal cord both centrally and peripherally. She was started on a course of intravenous corticosteroids and improvement was seen both clinically and on repeat imaging. This case demonstrates a rare complication to an asymptomatic COVID-19 infection and explores the potential neurotropic properties of COVID-19.
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Affiliation(s)
- Gabriel Lee
- Acute Internal Medicine, St Thomas' Hospital, London, UK
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12
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Jani C, Walker A, Al Omari O, Patel D, Heffess A, Wolpow E, Page S, Bourque D. Acute transverse myelitis in West Nile Virus, a rare neurological presentation. IDCases 2021; 24:e01104. [PMID: 33868926 PMCID: PMC8047179 DOI: 10.1016/j.idcr.2021.e01104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/28/2021] [Accepted: 03/28/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction West Nile Virus varies in presentation from asymptomatic to a febrile illness often associated with malaise, weakness and maculopapular rash. West Nile neuro-invasive disease often manifests as meningitis, encephalitis, and less commonly acute flaccid paralysis in a "polio-like" presentation. Acute transverse myelitis (ATM) is a rare manifestation. We present a case of neuro-invasive West Nile Virus infection with radiographic evidence of longitudinally extensive transverse myelitis (LETM), a subset of ATM. Case narration A 42-year-old male from Massachusetts presented with progressive asymmetric paralysis of 4 days duration after developing a prodrome of fever, neck stiffness and urinary retention. Physical examination demonstrated asymmetric lower extremity weakness Lumbar puncture revealed lymphocytic pleocytosis with normal protein and glucose and a positive West Nile IgM in CSF (4.89, reference <0.90), and West Nile Virus detected by PCR in CSF. His West Nile serum IgM was 3.03 (reference range <0.90) and IgG was <1.30 (reference range <1.30). MRI of the lumbar spine showed findings consistent with the diagnosis of ATM. Conclusion With our patient's presentation of acute onset asymmetrical weakness following a viral illness, we ruled out differentials including demyelinating syndrome such as GBS, inflammation of the meninges through meningitis or meningoencephalitis, or traumatic/ischemic involvement of the spinal cord directly. Due to the MRI findings, his motor weakness and urinary retention, supporting CSF findings and WNV positive serologies, ATM due to WNV infection was the main suspect for his presentation. Although ATM is an uncommon manifestation of WNV, it is imperative to consider this in the differential for patients presenting with acute onset flaccid paralysis in regions where WNV is endemic.
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Affiliation(s)
- Chinmay Jani
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Alexander Walker
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Omar Al Omari
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Dipesh Patel
- Harvard Medical School, Boston, MA, USA.,Department of Radiology, Mount Auburn Hospital, Cambridge, MA, USA
| | - Alejandro Heffess
- Harvard Medical School, Boston, MA, USA.,Department of Radiology, Mount Auburn Hospital, Cambridge, MA, USA
| | - Edward Wolpow
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Neurology, Mount Auburn Hospital, Cambridge, MA, USA
| | - Stephanie Page
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Daniel Bourque
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Infectious Disease, Mount Auburn Hospital, Cambridge, MA, USA
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13
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Abstract
Alphaviruses, members of the enveloped, positive-sense, single-stranded RNA Togaviridae family, represent a reemerging public health threat as mosquito vectors expand into new geographic territories. The Old World alphaviruses, which include chikungunya virus, Ross River virus, and Sindbis virus, tend to cause a clinical syndrome characterized by fever, rash, and arthritis, whereas the New World alphaviruses, which consist of Venezuelan equine encephalitis virus, eastern equine encephalitis virus, and western equine encephalitis virus, induce encephalomyelitis. Following recovery from the acute phase of infection, many patients are left with debilitating persistent joint and neurological complications that can last for years. Clues from human cases and studies using animal models strongly suggest that much of the disease and pathology induced by alphavirus infection, particularly atypical and chronic manifestations, is mediated by the immune system rather than directly by the virus. This review discusses the current understanding of the immunopathogenesis of the arthritogenic and neurotropic alphaviruses accumulated through both natural infection of humans and experimental infection of animals, particularly mice. As treatment following alphavirus infection is currently limited to supportive care, understanding the contribution of the immune system to the disease process is critical to developing safe and effective therapies.
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Affiliation(s)
- Victoria K Baxter
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Mark T Heise
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
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14
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Furtado VF, Melamud K, Hassan K, Rohatgi S, Buch K. Imaging manifestations of immune-related adverse effects in checkpoint inhibitor therapies: A primer for the radiologist. Clin Imaging 2020; 63:35-49. [PMID: 32120311 DOI: 10.1016/j.clinimag.2020.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/23/2020] [Accepted: 02/19/2020] [Indexed: 12/31/2022]
Abstract
Immune checkpoint inhibitors are monoclonal antibodies directed against cellular pathways on T-cells to treat different types of malignancies. This new therapy can cause immune-related adverse events that can involve almost any organ system. This article will review clinical presentations, molecular mechanisms and imaging manifestations of adverse events caused by checkpoint inhibitors and also illustrate the pseudoprogression tumor response pattern.
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Affiliation(s)
- Vanessa Fiorini Furtado
- Department of Hematology and Oncology, Boston Medical Center, Boston, MA, United States of America
| | - Kira Melamud
- Department of Abdominal Imaging, New York University, New York, NY, United States of America
| | - Khalid Hassan
- Department of Neuroradiology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Saurabh Rohatgi
- Department of Neuroradiology, University of Massachusetts Medical Center, Worcester, MA, United States of America
| | - Karen Buch
- Department of Neuroradiology, Massachusetts General Hospital, Boston, MA, United States of America.
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Qu F, Qu Z, Lv Y, Song B, Wu B. Disseminated Cryptococcosis revealed by transverse myelitis in Immunocompetent patient: a case report and review of the literature. BMC Neurol 2020; 20:13. [PMID: 31924167 PMCID: PMC6954520 DOI: 10.1186/s12883-020-1598-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 12/31/2019] [Indexed: 11/19/2022] Open
Abstract
Background Transverse myelitis (TM) is due to inflammatory spinal cord injury with bilateral neurologic involvement, which is sensory, motor, or autonomic in nature. It may be associated with autoimmune disease, vaccination, intoxication and infections. The most common infection cause of TM is Coxsackie virus and Mycoplasma pneumoniae. The cryptococcosis is rare. We present the case of disseminated cryptococcosis revealed by transverse myelitis in an immunocompetent 55-year-old male patient. The literature review is also stated. Case presentation The 55-year-old man suffered from gradual numbness, weakness in both lower limbs and finally paralyzed in the bed. The thoracic spine Computed tomography (CT) was normal, but multiple nodules in the lung were accidentally discovered. Thoracic Magnetic Resonance Imaging (MRI) showed diffused thoracic spinal cord thickening and extensively intramedullary T2 hyper intensity areas. Gadolinium contrast enhanced T1WI showed an intramedullary circle-enhanced nodule at 9th thoracic level. Diagnosis was made by histological examination of the bilateral lung biopsy. The patient was treated successfully with systemic amphotericin B liposome and fluconazole and intrathecal dexamethasone and amphotericin B liposome. Conclusions This is a patient with disseminated cryptococcosis involving the lung, spinal cord and adrenal glands, which is rare in the absence of immunodeficiency.
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Affiliation(s)
- Fangfang Qu
- Department of Respiratory and Critical Care Medicine, Institute of Respiratory Diseases, the Second Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China
| | - Zhenzhen Qu
- Department of Neurologic Medicine, the Second Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China
| | - Yingqian Lv
- Department of Medical Oncology, the Second Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China
| | - Bo Song
- The Public Health College, Hebei Medical University, Shijiazhuang, 050000, Hebei, China
| | - Bailin Wu
- Department of Radiology, the Second Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China.
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Corwell BN, Davis NL. The Emergent Evaluation and Treatment of Neck and Back Pain. Emerg Med Clin North Am 2019; 38:167-191. [PMID: 31757249 DOI: 10.1016/j.emc.2019.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Neck and back pain are among the most common symptom-related complaints for visits to the emergency department (ED). They contribute to high levels of lost work days, disability, and health care use. The goal of ED assessment of patients with neck and back pain is to evaluate for potentially dangerous causes that could result in significant morbidity and mortality. This article discusses the efficient and effective evaluation, management, and treatment of patients with neck and back pain in the ED. Emphasis is placed on vertebral osteomyelitis, epidural abscess, acute transverse myelitis, epidural compression syndrome, spinal malignancy, and spinal stenosis.
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Affiliation(s)
- Brian N Corwell
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA; Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Natalie L Davis
- Department of Pediatrics, University of Maryland School of Medicine, 110 S. Paca Street, 8th Floor, Baltimore, MD 21201, USA
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Schilling KG, By S, Feiler HR, Box BA, O'Grady KP, Witt A, Landman BA, Smith SA. Diffusion MRI microstructural models in the cervical spinal cord - Application, normative values, and correlations with histological analysis. Neuroimage 2019; 201:116026. [PMID: 31326569 DOI: 10.1016/j.neuroimage.2019.116026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/12/2019] [Accepted: 07/16/2019] [Indexed: 12/14/2022] Open
Abstract
Multi-compartment tissue modeling using diffusion magnetic resonance imaging has proven valuable in the brain, offering novel indices sensitive to the tissue microstructural environment in vivo on clinical MRI scanners. However, application, characterization, and validation of these models in the spinal cord remain relatively under-studied. In this study, we apply a diffusion "signal" model (diffusion tensor imaging, DTI) and two commonly implemented "microstructural" models (neurite orientation dispersion and density imaging, NODDI; spherical mean technique, SMT) in the human cervical spinal cord of twenty-one healthy controls. We first provide normative values of DTI, SMT, and NODDI indices in a number of white matter ascending and descending pathways, as well as various gray matter regions. We then aim to validate the sensitivity and specificity of these diffusion-derived contrasts by relating these measures to indices of the tissue microenvironment provided by a histological template. We find that DTI indices are sensitive to a number of microstructural features, but lack specificity. The microstructural models also show sensitivity to a number of microstructure features; however, they do not capture the specific microstructural features explicitly modelled. Although often regarded as a simple extension of the brain in the central nervous system, it may be necessary to re-envision, or specifically adapt, diffusion microstructural models for application to the human spinal cord with clinically feasible acquisitions - specifically, adjusting, adapting, and re-validating the modeling as it relates to both theory (i.e. relevant biology, assumptions, and signal regimes) and parameter estimation (for example challenges of acquisition, artifacts, and processing).
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Affiliation(s)
- Kurt G Schilling
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Samantha By
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Haley R Feiler
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bailey A Box
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kristin P O'Grady
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Atlee Witt
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bennett A Landman
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA; Department of Electrical Engineering, Vanderbilt University, Nashville, TN, USA
| | - Seth A Smith
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
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18
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Cömert P, Albayrak M, Yıldız A, Şahin O, Öztürk ÇP, Maral S, Güneş G, Afacan Öztürk HB, Sağlam B. An acute transverse myelitis attack after autologous stem cell transplantation: A rare case. Transfus Apher Sci 2019; 58:341-343. [DOI: 10.1016/j.transci.2019.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 03/25/2019] [Accepted: 05/08/2019] [Indexed: 11/25/2022]
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Dumic I, Vitorovic D, Spritzer S, Sviggum E, Patel J, Ramanan P. Acute transverse myelitis - A rare clinical manifestation of Lyme neuroborreliosis. IDCases 2018; 15:e00479. [PMID: 30622896 PMCID: PMC6317275 DOI: 10.1016/j.idcr.2018.e00479] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/22/2018] [Accepted: 12/23/2018] [Indexed: 11/20/2022] Open
Abstract
Acute transverse myelitis (ATM) is a rare, potentially devastating neurological syndrome that has variety of causes, infectious being one of them. Lyme disease (LD) is the most common vector borne zoonosis in the United States (U.S.). While neurologic complications of LD are common, acute transverse myelitis is an exceedingly rare complication. We present a case of a previously healthy 25-year-old man who presented with secondary erythema migrans, aseptic meningitis and clinical features of transverse myelitis including bilateral lower extremity motor and sensory deficits manifesting as weakness and numbness, urinary retention and constipation. Despite negative serum antibodies against Borrelia burgdoferi, cerebrospinal fluid (CSF) was positive for Borrelia burgdorferi PCR. Following treatment with methylprednisolone and ceftriaxone, he attained complete recovery apart from neurogenic bladder necessitating intermittent self-catheterization. We report rare manifestation of a common disease and emphasize the importance of considering LD in the differential diagnosis of acute transverse myelitis, particularly in residents of endemic areas.
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Affiliation(s)
- Igor Dumic
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, United States
- Mayo Clinic College of Medicine and Science, Rochester, MN, United States
| | - Danilo Vitorovic
- Department of Neurology, University of Vermont, Burlington, VT, United States
| | - Scott Spritzer
- Department of Neurology, Mayo Clinic Health System, Eau Claire, WI, United States
| | - Erik Sviggum
- Department of Radiology, Mayo Clinic Health System, Eau Claire, WI, United States
| | - Janki Patel
- Department of Infectious Disease, Mayo Clinic Health System, Eau Claire, WI, United States
| | - Poornima Ramanan
- Division of Infectious Diseases, North Memorial Health Hospital, Minneapolis, MN, United States
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Wu J, Cheng Y, Qin Z, Liu X, Liu Z. Effects of electroacupuncture on bladder and bowel function in patients with transverse myelitis: a prospective observational study. Acupunct Med 2018; 36:261-266. [PMID: 29909400 PMCID: PMC6089199 DOI: 10.1136/acupmed-2016-011225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2017] [Indexed: 11/06/2022]
Abstract
Objective To preliminarily explore the effect of electroacupuncture (EA) on bladder and bowel dysfunction in patients with transverse myelitis. Methods Sixteen participants were treated with EA at bilateral BL32, BL33, and BL35 once a day, five times a week for the first 4 weeks, and once every other day, three times a week for the following 4 weeks. Patients were then followed up for 6 months. Bladder and bowel function, and the safety of EA, were assessed. Results After 8 weeks of treatment, five (5/16, 31%) patients resumed normal voiding, three (6/16, 38%) regained partially normal voiding, and five (5/16, 31%) had no change. After treatment, the residual urine volume decreased by 100 mL (IQR 53–393 mL; P<0.05) in nine patients with bladder voiding dysfunction; in 11 patients with urinary incontinence, the number of weekly urinary incontinence episodes, 24-hour urinary episodes, and nocturia episodes per night diminished by 14 (95% CI 5 to 22), 5 (95% CI 1 to 9), and 4 (95% CI 0 to 7) episodes, respectively (all P<0.05). After 8 weeks of treatment in eight patients with faecal retention, four (4/8, 50%) resumed normal bowel movements, three (3/8, 38%) regained partially normal bowel movements, and one (1/8, 13%) had no change. Conclusions EA might be a promising alternative for the management of bladder and bowel dysfunction in patients with transverse myelitis. Randomised controlled trials are needed to confirm the effectiveness and safety of EA for this condition.
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Affiliation(s)
- Jiani Wu
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yanjun Cheng
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Zongshi Qin
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Xiaoxu Liu
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Zhishun Liu
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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Holroyd KB, Aziz F, Szolics M, Alsaadi T, Levy M, Schiess N. Prevalence and characteristics of transverse myelitis and neuromyelitis optica spectrum disorders in the United Arab Emirates: A multicenter, retrospective study. ACTA ACUST UNITED AC 2018; 9:155-161. [PMID: 30090123 DOI: 10.1111/cen3.12458] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Objective To determine the epidemiology and characteristics of transverse myelitis (TM) and neuromyelitis optica spectrum disorders (NMOSD) in Abu Dhabi, United Arab Emirates. Methods Retrospective chart review at four large government-run hospitals in Abu Dhabi between 2010 and 2016. Data collected included year of onset, presentation, laboratory results including aquaporin-4 immunoglobulin G (IgG)/myelin oligodendrocyte glycoprotein IgG antibodies and the occurrence of any relapses. Results A total of 46 individuals were identified. Of these, 23 (50%) were Emirati citizens. Within the overall group including pediatrics, the crude prevalence rate for monophasic TM was 1.0 per 100 000, and for NMOSD was 0.34 per 100 000. Incidence rates within the overall group for TM and NMOSD were 0.18 per 100 000 and 0.05 per 100 000, respectively. For Emirati citizens aged ≥20 years, the prevalence rate for monophasic TM was 2.46 per 100 000 and 1.76 per 100 000 for NMOSD, and the incidence was 0.57 per 100 000 and 0.17 per 100 000, respectively. The incidence of monophasic TM and NMOSD within the Emirati pediatric population (aged ≤19 years) was 0.18 per 100 000 and 0.06 per 100 000, respectively. The mean age of onset for monophasic TM was 36 years, and for NMOSD was 43 years. Nine patients had a positive aquaporin-4 IgG or anti-myelin oligodendrocyte glycoprotein IgG antibody result. Of the 30 participants with available laboratory cerebrospinal fluid analysis, 36.6% had elevated white blood counts (>5.0 × 106/L), and 43% had elevated protein levels. A total of 19 participants had documentation of oligoclonal bands or IgG index, and just four (21%) had either oligoclonal bands or elevated IgG index. Conclusion The present study describes the epidemiology and characteristics of TM and NMOSD among populations in Abu Dhabi. The adult prevalence rate for Emirati citizens was 2.46 per 100 000 for monophasic TM, and 1.76 per 100 000 for NMOSD. The overall incidence was 0.18 per 100 000 and 0.05 per 100 000, respectively.
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Affiliation(s)
- Kathryn B Holroyd
- Partners Neurology Residency, Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Faisal Aziz
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates
| | - Miklos Szolics
- Department of Neurology, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates
| | - Taoufik Alsaadi
- Neurology Department, American Center for Psychiatry and Neurology, Al Ain, Abu Dhabi, United Arab Emirates
| | - Michael Levy
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicoline Schiess
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Abstract
This article describes a young, otherwise healthy woman who presented to the ED with numbness in her feet and was discharged. Twenty-four hours later, she returned because of difficulty walking; in 48 hours she could not walk without assistance. Although Guillain-Barré syndrome was suspected initially, the patient's weakness, sensory loss, and autonomic dysfunction eventually were diagnosed as transverse myelitis, a myelopathy often associated with infectious or autoimmune diseases. The article describes the presentation, diagnostic evaluation and criteria, treatment, and prognosis of transverse myelitis.
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23
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Jo Yaphockun KK, Wai S. Neurosyphilis as a Cause of Transverse Myelitis in a Teenage Girl. J Emerg Med 2018; 54:651-655. [PMID: 29602529 DOI: 10.1016/j.jemermed.2018.01.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/24/2017] [Accepted: 01/25/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Syphilis is a sexually transmitted infection that was nearly eradicated in 2001 but is now making a resurgence. It has a wide range of clinical manifestations depending on disease stage. Neurosyphilis is an infrequently seen infectious disease with central nervous system involvement that can occur in either early- or late-stage syphilis. The diagnosis of neurosyphilis is challenging, primarily because Treponema pallidum, the infecting organism, cannot be cultured in vitro. This article describes a patient with neurosyphilis and reviews the epidemiology and clinical manifestations, diagnostics, and treatment of neurosyphilis. CASE REPORT In compliance with the request of the Privacy Board of our institution, the numerical age of this patient has been omitted. A sexually active teenage girl who was treated for primary syphilis 2 years earlier presented to a tertiary children's hospital with paresthesia and weakness of her right leg, left arm, and neck. Magnetic resonance imaging revealed cervical intramedullary cord edema consistent with transverse myelitis. Serum studies showed positive syphilis enzyme immunoassay, T. pallidum particle agglutination assay, and fluorescent treponemal antibody absorption. A serum rapid plasma reagin test was negative. A lumbar puncture was performed with normal cell count and protein. A cerebrospinal fluid Venereal Disease Research Laboratory test was negative. She was diagnosed with neurosyphilis and treated with intravenous steroids and penicillin G, with near complete resolution of symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The Centers for Disease Control and prevention has noted a steady rise of the incidence of syphilis since 2002. Emergency physicians should be familiar with the spectrum of the clinical manifestations of syphilis, challenges in diagnostics, and appropriate treatment course.
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Affiliation(s)
- Karen Kim Jo Yaphockun
- Department of Emergency Medicine, Rady Children's Hospital San Diego, University of California San Diego, San Diego, California
| | - Shannon Wai
- Department of Emergency Medicine, Rady Children's Hospital San Diego, University of California San Diego, San Diego, California
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24
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25
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Akute Lähmungen bei einem Jugendlichen. Monatsschr Kinderheilkd 2015. [DOI: 10.1007/s00112-015-3473-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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26
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Wadia S, Padmanabhan P, Moeller K, Rominger A. Pediatric Surfer's Myelopathy. J Emerg Med 2015; 49:e143-5. [DOI: 10.1016/j.jemermed.2015.06.065] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 06/24/2015] [Indexed: 11/24/2022]
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Montalván V, Gallo M, Rojas E. A 25 years-old woman with a postvaccine thalamic pseudotumoral lesion. Rev Clin Esp 2015; 215:468-72. [PMID: 26298546 DOI: 10.1016/j.rce.2015.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 07/14/2015] [Accepted: 07/14/2015] [Indexed: 11/25/2022]
Affiliation(s)
- V Montalván
- Departamento de Neurología, Hospital Guillermo Almenara, Lima, Perú.
| | - M Gallo
- Departamento de Neurología, Hospital Guillermo Almenara, Lima, Perú
| | - E Rojas
- Departamento de Neurología, Hospital Guillermo Almenara, Lima, Perú
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28
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Ma T, Wu X, Cai Q, Wang Y, Xiao L, Tian Y, Li H. Lead Poisoning Disturbs Oligodendrocytes Differentiation Involved in Decreased Expression of NCX3 Inducing Intracellular Calcium Overload. Int J Mol Sci 2015; 16:19096-110. [PMID: 26287169 PMCID: PMC4581288 DOI: 10.3390/ijms160819096] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 07/28/2015] [Accepted: 08/06/2015] [Indexed: 01/03/2023] Open
Abstract
Lead (Pb) poisoning has always been a serious health concern, as it permanently damages the central nervous system. Chronic Pb accumulation in the human body disturbs oligodendrocytes (OLs) differentiation, resulting in dysmyelination, but the molecular mechanism remains unknown. In this study, Pb at 1 μM inhibits OLs precursor cells (OPCs) differentiation via decreasing the expression of Olig 2, CNPase proteins in vitro. Moreover, Pb treatment inhibits the sodium/calcium exchanger 3 (NCX3) mRNA expression, one of the major means of calcium (Ca2+) extrusion at the plasma membrane during OPCs differentiation. Also addition of KB-R7943, NCX3 inhibitor, to simulate Pb toxicity, resulted in decreased myelin basic protein (MBP) expression and cell branching. Ca2+ response trace with Pb and KB-R7943 treatment did not drop down in the same recovery time as the control, which elevated intracellular Ca2+ concentration reducing MBP expression. In contrast, over-expression of NCX3 in Pb exposed OPCs displayed significant increase MBP fluorescence signal in positive regions and CNPase expression, which recovered OPCs differentiation to counterbalance Pb toxicity. In conclusion, Pb exposure disturbs OLs differentiation via affecting the function of NCX3 by inducing intracellular calcium overload.
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Affiliation(s)
- Teng Ma
- Department of Histology and Embryology, Third Military Medical University, Chongqing 400038, China.
- Battalion 7 of Cadet Brigade, Third Military Medical University, Chongqing 400038, China.
| | - Xiyan Wu
- Department of Histology and Embryology, Third Military Medical University, Chongqing 400038, China.
| | - Qiyan Cai
- Department of Histology and Embryology, Third Military Medical University, Chongqing 400038, China.
| | - Yun Wang
- Department of Histology and Embryology, Third Military Medical University, Chongqing 400038, China.
| | - Lan Xiao
- Department of Histology and Embryology, Third Military Medical University, Chongqing 400038, China.
| | - Yanping Tian
- Department of Histology and Embryology, Third Military Medical University, Chongqing 400038, China.
| | - Hongli Li
- Department of Histology and Embryology, Third Military Medical University, Chongqing 400038, China.
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Condie AG, Gerson SL, Miller RH, Wang Y. Two-photon fluorescent imaging of myelination in the spinal cord. ChemMedChem 2012; 7:2194-203. [PMID: 23136014 DOI: 10.1002/cmdc.201200343] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Indexed: 11/11/2022]
Abstract
Myelination is a fundamental biological process in the vertebrate nervous system. Damage to or malformation of myelin can lead to various neurological diseases; for example, demyelination in the spinal cord is a major cause of paralysis of patients suffering from multiple sclerosis and related diseases. The ability to directly track myelin levels in the spinal cord is needed in order to assess the efficacy of therapeutics in promoting myelin repair. To address this unmet need, 4-((E)-4-((E)-4-aminostyryl)-2,5-dimethoxystyryl)-N-methylaniline, known as Case Imaging Compound (CIC), has been developed as a myelin-targeted fluorescent imaging agent that selectively binds to myelin. CIC was synthesized via an improved route and evaluated as a fluorescent probe for two-photon fluorescent imaging of myelin in the spinal cord in both demyelinated and dysmyelinated models. In vitro and ex vivo tissue staining both suggest that CIC selectively binds to in animal models. Further evaluation in animal models indicated that CIC is sensitive to differences in myelin content in healthy versus pathological myelin. CIC could potentially be useful in the development and evaluation of novel therapies for multiple sclerosis and other demyelinating diseases.
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Affiliation(s)
- Allison G Condie
- Division of Radiopharmaceutical Science, Case Center for Imaging Research, Department of Radiology, Chemistry, and Biomedical Engineering, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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Wolf VL, Lupo PJ, Lotze TE. Pediatric acute transverse myelitis overview and differential diagnosis. J Child Neurol 2012; 27:1426-36. [PMID: 22914370 DOI: 10.1177/0883073812452916] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute transverse myelitis is a clinical syndrome affecting the spinal cord, which is characterized by acute onset of motor, sensory, and autonomic dysfunction. Approximately 20% of cases of acute transverse myelitis occur in children. This review summarizes the current published literature on acute transverse myelitis, including epidemiology, diagnostic criteria, pathogenesis, clinical presentation, clinical evaluation, and differential diagnosis. The article also summarizes the neuroimaging features, acute and chronic complications, treatments, and prognosis of acute transverse myelitis in the pediatric population. The initial evaluation centers on differentiation from other causes of myelopathy, and cases are further divided into idiopathic or disease-associated acute transverse myelitis. Correct diagnosis is important for treatment and prognosis. Treatment begins with intensive surveillance for acute life-threatening respiratory or autonomic complications. Immunomodulating therapy is recommended for noninfectious causes, using high-dose intravenous corticosteroids or plasma exchange. Other therapeutic options are also discussed. Prognosis depends on a number of factors, and evidence suggests that the majority of children have a good outcome. A small percentage of children diagnosed with acute transverse myelitis later are diagnosed with other demyelinating diseases, especially neuromyelitis optica, or multiple sclerosis. The most common long-term complications of acute transverse myelitis are urinary, motor, or sensory dysfunction.
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Ji S, Doucette JR, Nazarali AJ. Sirt2 is a novel in vivo downstream target of Nkx2.2 and enhances oligodendroglial cell differentiation. J Mol Cell Biol 2011; 3:351-9. [DOI: 10.1093/jmcb/mjr009] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Transverse myelopathy mimicking conus medullaris syndrome. JAAPA 2011. [DOI: 10.1097/01720610-201106000-00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Geber C, Baumgärtner U, Fechir M, Vogt T, Birklein F, Treede RD. Comparison of LEP and QST and their contribution to standard sensory diagnostic assessment of spinal lesions: a pilot study. Neurol Sci 2011; 32:401-10. [PMID: 21293898 DOI: 10.1007/s10072-011-0476-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Accepted: 01/04/2011] [Indexed: 10/18/2022]
Abstract
This study evaluates the additional use of laser-evoked potentials (LEP) and quantitative sensory testing (QST) in the sensory assessment of spinal lesions. Four consecutive patients with spinal lesions verified by MRI and clinical evidence for mild spinothalamic tract involvement were included. The electrophysiological workup [somatosensory evoked potentials (SEP) and LEP] was compared to QST. Electrophysiology and QST were reassessed after about 6 months. LEP detected impaired spinothalamic tract function in 7/8 examinations. QST pointed to spinothalamic tract lesions by loss of thermal function (3/8); most frequent positive sensory signs (3/8) were paradoxical heat sensations. LEP and QST results were concordant in 6/8 examinations. SEPs were abnormal in 2/8 examinations. Congruent results between SEP and both LEP and QST were obtained in 3/8 examinations. LEP detected more deficits than any single QST parameter or their combination but additional QST allows the detection of positive sensory signs. The diagnostic gain of SEP was limited.
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Affiliation(s)
- Christian Geber
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes-Gutenberg Universität, Langenbeckstrasse 1, 55131 Mainz, Germany.
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Walczak P, All AH, Rumpal N, Gorelik M, Kim H, Maybhate A, Agrawal G, Campanelli JT, Gilad AA, Kerr DA, Bulte JWM. Human glial-restricted progenitors survive, proliferate, and preserve electrophysiological function in rats with focal inflammatory spinal cord demyelination. Glia 2010; 59:499-510. [PMID: 21264955 DOI: 10.1002/glia.21119] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Accepted: 11/09/2010] [Indexed: 12/20/2022]
Abstract
Transplantation of glial progenitor cells results in transplant-derived myelination and improved function in rodents with genetic dysmyelination or chemical demyelination. However, glial cell transplantation in adult CNS inflammatory demyelinating models has not been well studied. Here we transplanted human glial-restricted progenitor (hGRP) cells into the spinal cord of adult rats with inflammatory demyelination, and monitored cell fate in chemically immunosuppressed animals. We found that hGRPs migrate extensively, expand within inflammatory spinal cord lesions, do not form tumors, and adopt a mature glial phenotype, albeit at a low rate. Human GRP-transplanted rats, but not controls, exhibited preserved electrophysiological conduction across the spinal cord, though no differences in behavioral improvement were noted between the two groups. Although these hGRPs myelinated extensively after implantation into neonatal shiverer mouse brain, only marginal remyelination was observed in the inflammatory spinal cord demyelination model. The low rate of transplant-derived myelination in adult rat spinal cord may reflect host age, species, transplant environment/location, and/or immune suppression regime differences. We conclude that hGRPs have the capacity to myelinate dysmyelinated neonatal rodent brain and preserve conduction in the inflammatory demyelinated adult rodent spinal cord. The latter benefit is likely dependent on trophic support and suggests further exploration of potential of glial progenitors in animal models of chronic inflammatory demyelination.
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Affiliation(s)
- Piotr Walczak
- Russell H. Morgan Department of Radiology and Radiological Science, Division of MR Research, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA.
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Rose JJ, Bealmear B, Nedelkoska L, Studzinski D, Lisak RP, Benjamins JA. Cytokines decrease expression of interleukin-6 signal transducer and leptin receptor in central nervous system glia. J Neurosci Res 2009; 87:3098-106. [DOI: 10.1002/jnr.22135] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Diagnostic workup of patients with acute transverse myelitis: spectrum of clinical presentation, neuroimaging and laboratory findings. Spinal Cord 2008; 47:312-7. [DOI: 10.1038/sc.2008.143] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Noorbakhsh F, Johnson RT, Emery D, Power C. Acute disseminated encephalomyelitis: clinical and pathogenesis features. Neurol Clin 2008; 26:759-80, ix. [PMID: 18657725 PMCID: PMC7132764 DOI: 10.1016/j.ncl.2008.03.009] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM) is an immune-mediated disorder of the central nervous system (CNS). Disease typically starts with an abrupt onset of neurologic symptoms and signs within days to weeks after a viral infection or immunization. Neuropathological examination of the CNS in ADEM reveals involvement of white matter, with infiltration of monocytoid cells and perivenous demyelination.
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Affiliation(s)
- Farshid Noorbakhsh
- Department of Medicine (Neurology), University of Alberta, Edmonton, Alberta, T6G 2S2, Canada
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Thurnher MM, Cartes-Zumelzu F, Mueller-Mang C. Demyelinating and infectious diseases of the spinal cord. Neuroimaging Clin N Am 2007; 17:37-55. [PMID: 17493538 DOI: 10.1016/j.nic.2006.12.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Spinal cord diseases generally have distinctive clinical findings that reflect dysfunction of particular sensory or motor tracts. The abnormalities on MR images reflect the pathologic changes that occur in the affected pathways. The complexity and the wide spectrum of diseases affecting the spinal cord require a profound knowledge of neuropathology and exactly tuned imaging strategies. This article describes and illustrates the clinical and imaging characteristics in various demyelinating and infectious conditions of the spinal cord.
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Affiliation(s)
- Majda M Thurnher
- Department of Radiology, Neuroradiology Section, Medical University of Vienna, Waehringer Guertel 18-20, Vienna A-1090, Austria.
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