Transverse myelitis

Zika and Dengue Virus Autoimmunity: An Overview of Related Disorders and Their Potential Mechanisms

Zika virus (ZIKV) and dengue virus (DENV) are two major mosquito-borne flaviviruses that pose a significant threat to the global public health system, particularly in tropical regions. The clinical outcomes related to these viral pathogens can vary from self-limiting asymptomatic infections to various forms of life-threatening pathological conditions such as haemorrhagic disorders. In addition to the direct effects of the viral pathogens, immune processes play also a significant function in the development of diseases mediated by ZIKV and DENV. Studing these processes is important for developing safer vaccines and targeted therapeutic strategies. These viruses have been reported to trigger various autoimmune disorders affecting different parts of human organ systems. It also has been shown that preexisting immunity to ZIKV or DENV can impact the outcome of subsequent infections caused by another virus. ZIKV and DENV infection can promote the development of autoimmune disorders by different mechanisms, such as molecular mimicry and autoantibody formation. The present review provides an overview of various autoimmune disorders associated with ZIKV and DENV infection and their potential underlying mechanisms.

Zika virus infection and acute transverse myelitis: a comprehensive systematic review

The Zika virus (ZIKV) has been associated with several complications, including acute transverse myelitis (ATM), an acute inflammation of the spinal cord, with rapid development of motor, sensory and dysautonomic symptoms. It is a rare disease, and its clinical features, as well as differences in relation to idiopathic ATMs, are still not completely known. The objective of this paper is to review the literature in search of clinical features and complementary exams of ATM post-ZIKV infection, alone or in association with other neurological conditions (mixed diseases), as well as its treatments and prognoses. The search was made on 5 databases, using the PRISMA methodology (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Nine articles were selected (total of 20 subjects), which were divided between isolated ATM and mixed neurological syndromes with ATM. The study found a predominance of individuals aged 20 to 30. Among the six subjects in the mixed group, three were over 50 years old. The median prodromal period was 2 days for the mixed diseases group and 7 days for the isolated ATM group. Some individuals in the isolated ATM group exhibited signs of dysautonomia, such as syncope, postural lability, and arrhythmia. The mixed group had a higher incidence of coinfections, with 4 cases compared to 1 case in the isolated ATM group. Over 50% of the individuals had moderate to moderately severe disability. These findings suggest that severe conditions may progress to significant sequelae, highlighting the need for prompt diagnosis and treatment, particularly during endemic periods.

Transverse Myelitis in a Healthy Adult Female Patient: A Rare Viral Etiology

Transverse myelitis (TM) is an uncommon but extensively documented neurological disorder marked by acute spinal cord inflammation, resulting in a spectrum of impairments including motor, sensory, and autonomic disturbances. We outline a rare case of viral-induced TM linked to COVID-19 and Coxsackie B viral infections. A 25-year-old healthy female patient presented with acute bilateral upper and lower extremity weakness, paresthesia, and urinary retention. MRI of the cervical spine revealed abnormal marrow signal intensity. Laboratory investigation highlighted the presence of SARS-CoV-2 RNA; Coxsackie B virus subtypes 1, 2, 4, 5, and 6; and positive Lyme disease IgG subtype. Lumbar puncture and systemic autoimmune cases of myelopathy were unrevealing. Treatment included high-dose steroids, plasmapheresis, Foley catheter placement, and continual physical therapy. Despite improvements, the patient did not reach baseline and was discharged for outpatient physical/occupational rehabilitation. To our knowledge, this is the only case that describes viral-induced TM associated with COVID-19, Coxsackie B, and Lyme disease simultaneously. The rarity of this case highlights the necessity for further investigation into the pathogenesis of viral-induced TM and whether viral causes contribute synergistically or independently to the onset of TM.

Severe Transverse Myelitis Following Ankle Surgery Potentially Unmasking Late-Onset Systemic Lupus Erythematosus

A 70-year-old female underwent open reduction and internal fixation (ORIF) of her right ankle following a mechanical trip and fell two weeks before hospital admission. Two weeks following surgery, the patient experienced sudden-onset bilateral anterior thigh paresthesias and burning mid-back pain. Over the ensuing two days, the patient developed bilateral lower extremity weakness, bilateral lower extremity numbness, and urinary retention with constipation, which led to hospital presentation. A non-contrast cervical/thoracic/lumbar spine MRI on the day of admission revealed a possible syrinx from T3-T12. A repeat thoracic spine MRI revealed enhancement of the spinal cord at T9-T10 and T11-T12, suggestive of transverse myelitis or spinal cord infarction. Initiation of IV methylprednisolone sodium succinate improved strength and sensation, and IVIG (intravenous immunoglobulin) therapy was initiated. Transverse myelitis is typically idiopathic or attributed to infectious causes or systemic autoimmune conditions. Spinal cord injury remained high on the differential diagnosis, considering transverse myelitis rarely presents in the postoperative period. While methylprednisolone sodium succinate is the first-line treatment for transverse myelitis, its role remains unclear in treating spinal cord injury. Given the patient's positive response to methylprednisolone sodium succinate, an autoimmune panel was sent to determine the underlying etiology, resulting in a positive ANA (antinuclear antibody) and anti-dsDNA. Thus, transverse myelitis may be an initial presentation of systemic lupus erythematosus (SLE). In rare cases of spinal cord injury versus immune-mediated disorders affecting the spinal cord, corticosteroid treatment should be considered pending diagnosis confirmation.

Physical therapy intervention improves pain, mobility, and strength in a patient with transverse myelitis seropositive to Chikungunya: Case report

INTRODUCTION

Chikungunya Fever is an arbovirus transmitted by Aedes aegypti or Aedes albopictus mosquitoes. Neurological manifestations associated with arboviruses such as Dengue and Zika Virus were reported between 2017 and 2019.

AIM

To describe the impact of physical therapy management on pain, mobility, and strength for a patient with transverse myelitis seropositive to Chikungunya.

METHODS

A 29-year-old patient with transverse myelitis due to Chikungunya virus infection was subjected to physiotherapeutic evaluation and intervention for the management of pain, mobility, and lower limb strength. Pain intensity, tactile sensitivity for light touch and pain, and thermal sensitivity were assessed by the Numeric Pain Rating Scale (NPRS), aesthesiometer and pin-prick stimulator, and hot/cold test tubes, respectively. Functional mobility and lower limbs strength were assessed by the Timed Up and Go (TUG) test and the 30-s Chair-Stand test (30 CST), respectively. The physiotherapeutic protocol included kinesiotherapy, Transcutaneous Electrical Nerve Stimulation, and Functional Electrical Stimulation.

RESULTS

After 20 sessions of a multimodal physical therapy intervention, all joints tested by NPRS showed pain reduction: lumbar spine (57.15%), hip and ankles (100%), right knee (28.58%), and left knee (33.34%).There was an improvement in performing the TUG test at "getting up" and "sitting down" phases (decrease of 30% and 23%, respectively), while the number of repetitions in the 30 TFC increased by 75%, in addition, there was an improvement in performance in the tests, with more autonomy and independence.

CONCLUSION

At the end of the physiotherapeutic intervention, pain, mobility, and strength of the lower limbs were improved.

Longitudinally transverse myelitis as a rare complication of pneumococcal meningitis: case report

Pneumococcal meningitis is the most severe bacterial meningitis rarely complicated by acute myelitis. We report a case of a 54-year-old female who presented with pneumococcal meningoencephalitis. After eight days of hospitalization, the patient presented a sudden onset of bilateral lower leg weakness and bladder and bowel sphincter dysfunction. A neurological examination revealed a flaccid paraplegia. A magnetic resonance imaging (MRI) of the brain and the complete spinal cord was performed and showed cervical and thoracic myelitis. The patient was successfully treated with antibiotics and intravenous steroids. This case emphasizes the importance of considering myelitis as an acute complication of bacterial pneumococcal meningitis, with a good prognosis depending on early recognition and administration of appropriate therapy.

Successful Treatment of Epstein-Barr Virus Reactivation-associated Transverse Myelitis Following Herpes Zoster with Intravenous Rituximab in a Cord Blood Transplant Recipient

The Epstein-Barr virus (EBV) is associated with many malignancies and autoimmune diseases, including multiple sclerosis. In addition, EBV rarely but occasionally causes central nervous system (CNS) complications. We herein report a case of transverse myelitis (TM) associated with systemic EBV reactivation after herpes zoster infection in a cord blood transplant recipient. Identification of EBV-infected peripheral blood cells revealed a predominance of B cells. Notably, intravenous rituximab ameliorated EBV reactivation and TM. Since the CNS infiltration rate of intravenous rituximab is markedly low, the clinical efficacy of rituximab against TM suggests that EBV reactivation may cause TM via immune-mediated mechanisms.

Longitudinally Extensive Transverse Myelitis in a Patient With Systemic Lupus Erythematosus: A Case Report and Literature Review

Longitudinally extensive transverse myelitis (LETM) is a rare but severe neurological complication of systemic lupus erythematosus (SLE). The existing literature contains only limited information about this condition. We present a case of a 38-year-old female with SLE who presented with quadriparesis. Magnetic resonance imaging (MRI) of the brain and spinal cord showed T2-weighted high signal intensity involving the brainstem, bilateral middle and inferior cerebellar peduncles, and C1-C7 spinal cord segments. Early intervention with high-dose methylprednisolone and cyclophosphamide was initiated, resulting in partial clinical recovery. A comprehensive literature review highlights the importance of early diagnosis and treatment, discusses the potential etiologies, and explores the prognostic factors influencing patient outcomes. This case report underscores the need for a high level of clinical suspicion and prompt therapeutic intervention to improve prognosis in SLE patients presenting with LETM.

Newly identified adverse events for gemcitabine using the Food and Drug Administration Adverse Event Reporting System

BACKGROUND

Our research aimed to identify previously undocumented adverse events (AEs) in the gemcitabine drug insert with the goal of informing clinical practice.

METHODS

We extracted adverse events associated with gemcitabine use through 2023 using the Food and Drug Administration Adverse Event Reporting System (FAERS) database. Four algorithms (Reporting Odds Ratio, Proportional Reporting Ratio, Bayesian Confidence Propagation Neural Network, and Empirical Bayesian Geometric Mean) were employed to detect new AE signals. AEs were considered positive signals only if they were detected by all four algorithms.

RESULTS

From 2014 to 2023, a total of 42,360 AEs were reported in 14,905 individuals following gemcitabine use. These AEs totaled 437 preferred terms (PTs) across 20 system organ classes (SOCs). We identified unexpected AEs related to the ocular disorders, the nervous system, and the ear and the labyrinth. The ocular organ system will present with retinopathy, purtscher retinopathy, choroidal effusion, amaurosis, necrotizing scleritis, etc. The nervous system may experience reversible posterior encephalopathy syndrome, cerebellar syndrome, cauda equina syndrome, athetosis, transverse myelitis, etc. The ears and labyrinth may exhibit ototoxicity.

CONCLUSION

Our study identified previously undetected signals following gemcitabine treatment, thereby providing new insights for future medication guidance.

Transverse Myelitis in a 72-Year-Old Male Presenting With Upper Extremity Weakness

Acute transverse myelitis (TM) is a rare, acquired neuro-immune spinal cord disorder that can be idiopathic or related to a secondary disease. Clinical signs and symptoms include motor weakness, sensory alterations, and bowel or bladder dysfunction. Often TM occurs in the younger population or middle-aged adults. This patient's presentation is unique in the fact that he does not fall into either of these age categories. In this case, a 72-year-old male with a past medical history of hypertension and type 2 diabetes mellitus presented to the emergency department due to a five-day history of worsening weakness of the upper extremities bilaterally. In addition, the patient reported a new onset of abdominal wall numbness. The patient reported being at a theme park a few days prior, denying any injuries and only complaining of neck discomfort during the car ride home. Labs and imaging were quickly ordered for diagnostic purposes. The patient was diagnosed with TM using magnetic resonance imaging (MRI), lumbar puncture, and clinical signs. The etiology was later discovered to be due to a new diagnosis of Sjögren's autoimmune disease. The patient was treated with high-dose intravenous steroids for five days while being monitored for any neurologic changes. The plan was to continue steroids by mouth once discharged from the hospital. Due to poor adherence to discharge instructions, the patient was readmitted after presenting to the emergency department with worsening symptoms. Physicians need to recognize and diagnose TM quickly, as some etiologies are treatable and can prevent further damage to the spinal cord.

Astrocytic stress response is induced by exposure to astrocyte-binding antibodies expressed by plasmablasts from pediatric patients with acute transverse myelitis

BACKGROUND

Pediatric acute transverse myelitis (ATM) accounts for 20-30% of children presenting with a first acquired demyelinating syndrome (ADS) and may be the first clinical presentation of a relapsing ADS such as multiple sclerosis (MS). B cells have been strongly implicated in the pathogenesis of adult MS. However, little is known about B cells in pediatric MS, and even less so in pediatric ATM. Our lab previously showed that plasmablasts (PB), the earliest B cell subtype producing antibody, are expanded in adult ATM, and that these PBs produce self-reactive antibodies that target neurons. The goal of this study was to examine PB frequency and phenotype, immunoglobulin selection, and B cell receptor reactivity in pediatric patients presenting with ATM to gain insight to B cell involvement in disease.

METHODS

We compared the PB frequency and phenotype of 5 pediatric ATM patients and 10 pediatric healthy controls (HC) and compared them to previously reported adult ATM patients using cytometric data. We purified bulk IgG from the plasma samples and cloned 20 recombinant human antibodies (rhAbs) from individual PBs isolated from the blood. Plasma-derived IgG and rhAb autoreactivity was measured by mean fluorescence intensity (MFI) in neurons and astrocytes of murine brain or spinal cord and primary human astrocytes. We determined the potential impact of these rhAbs on astrocyte health by measuring stress and apoptotic response.

RESULTS

We found that pediatric ATM patients had a reduced frequency of peripheral blood PB. Serum IgG autoreactivity to neurons in EAE spinal cord was similar in the pediatric ATM patients and HC. However, serum IgG autoreactivity to astrocytes in EAE spinal cord was reduced in pediatric ATM patients compared to pediatric HC. Astrocyte-binding strength of rhAbs cloned from PBs was dependent on somatic hypermutation accumulation in the pediatric ATM cohort, but not HC. A similar observation in predilection for astrocyte binding over neuron binding of individual antibodies cloned from PBs was made in EAE brain tissue. Finally, exposure of human primary astrocytes to these astrocyte-binding antibodies increased astrocytic stress but did not lead to apoptosis.

CONCLUSIONS

Discordance in humoral immune responses to astrocytes may distinguish pediatric ATM from HC.

Case Report: The Rehabilitation of a Patient with Acute Transverse Myelitis after COVID-19 Vaccination

We report the case of a 55-year-old man with multi-symptomatic transverse myelitis after vaccination against coronavirus disease 2019 (COVID-19). The patient was diagnosed based on the course of the disease and the results of imaging and laboratory tests. We excluded other most probable causes of the disease. The quick start of diagnosis allowed for early treatment with intravenous steroids and then plasmapheresis and the implementation of modern rehabilitation methods using biofeedback platforms, among others, and an exoskeleton. The patient returned to work, but the rehabilitation process continues to this day due to persistent symptoms that impair the patient's quality of life.

Transverse Myelitis: A Case-Based Discussion of Infectious Etiologies

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.

Autoimmune diseases of the spine and spinal cord

Magnetic resonance imaging (MRI) and clinicopathological tools have led to the identification of a wide spectrum of autoimmune entities that involve the spine. A clearer understanding of the unique imaging features of these disorders, along with their clinical presentations, will prove invaluable to clinicians and potentially limit the need for more invasive procedures such as tissue biopsies. Here, we review various autoimmune diseases affecting the spine and highlight salient imaging features that distinguish them radiologically from other disease entities.

Concurrent transverse myelitis and acute inflammatory demyelinating polyneuropathy

A woman in her 40s presented with thoracic banding dysaesthesia and lower motor neuron weakness. Spinal imaging revealed a short segment of transverse myelitis and neurophysiology was suggestive of concurrent acute inflammatory demyelinating polyneuropathy. The patient improved with consecutive intravenous immunoglobulin and methylprednisolone treatment. Acute inflammatory demyelinating polyneuropathy is a progressive immune-mediated peripheral neuropathy which responds to intravenous immunoglobulin or plasmapheresis, whereas transverse myelitis is a central inflammatory syndrome usually treated with corticosteroid. We highlight differentiating features of the clinical presentation and the utility of investigations such as neurophysiology and MRI along with a review of treatment and the role for corticosteroid therapy.

Acute disseminated encephalomyelitis and transverse myelitis following COVID-19 vaccination - A self-controlled case series analysis

Acute Disseminated Encephalomyelitis (ADEM) and Transverse Myelitis (TM) are within the group of immune mediated disorders of acquired demyelinating syndromes. Both have been described in temporal association following various vaccinations in case reports and case series and have been evaluated in observational studies. A recent analysis conducted by The Global Vaccine Data Network (GVDN) observed an excess of ADEM and TM cases following the adenoviral vectored ChAdOx1 nCoV-19 (AZD1222) and mRNA-1273 vaccines, compared with historically expected background rates from prior to the pandemic. Further epidemiologic studies were recommended to explore these potential associations. We utilized an Australian vaccine datalink, Vaccine Safety Health-Link (VSHL), to perform a self-controlled case series analysis for this purpose. VSHL was selected for this analysis as while VSHL data are utilised for GVDN association studies, they were not included in the GVDN observed expected analyses. The VSHL dataset contains vaccination records sourced from the Australian Immunisation Register, and hospital admission records from the Victorian Admitted Episodes Dataset for 6.7 million people. These datasets were used to determine the relative incidence (RI) of G040 (ADEM) and G373 (TM) ICD-10-AM coded admissions in the 42-day risk window following COVID-19 vaccinations as compared to control periods either side of the risk window. We observed associations between ChAdOx1 adenovirus vector COVID-19 vaccination and ADEM (all dose RI: 3.74 [95 %CI 1.02,13.70]) and TM (dose 1 RI: 2.49 [95 %CI: 1.07,5.79]) incident admissions. No associations were observed between mRNA COVID-19 vaccines and ADEM or TM. These findings translate to an extremely small absolute risk of ADEM (0.78 per million doses) and TM (1.82 per million doses) following vaccination; any potential risk of ADEM or TM should be weighed against the well-established protective benefits of vaccination against COVID-19 disease and its complications. This study demonstrates the value of the GVDN collaboration leveraging large population sizes to examine important vaccine safety questions regarding rare outcomes, as well as the value of linked population level datasets, such as VSHL, to rapidly explore associations that are identified.

VISIBL-MS: A bilingual educational framework to increase awareness of early multiple sclerosis

BACKGROUND

Despite advancements in treatments of multiple sclerosis (MS), there is a lack of awareness of early MS symptoms, especially in students and the public, contributing to delays in diagnosis and treatment. This review aims to identify gaps in tools to increase awareness and to provide a bilingual framework to facilitate recognition of early MS symptoms.

METHODS

We performed a literature review to determine the use of English and Spanish mnemonics in MS education for medical students and patients.

RESULTS

There is no educational tool to help remember the early signs of MS at present. Here we present a framework for early awareness encompassed in the bilingual mnemonics VISIBLY (English) and VISIBLE (Spanish). VISIBLY stands for (1) Vision changes: Painful vision loss, loss of color vision or double vision; (2) Belly or Back numbness and Balance issues; (3) Limb weakness or Numbness; (4), Young people. Spanish version is included in the manuscript.

CONCLUSION

We posit that VISIBL-MS provides a framework for MS awareness that addresses the interconnection between language, culture, health literacy, and health outcomes and can be a useful educational tool to tackle the effects of health literacy on diverse communities.

Post-infectious Transverse Myelitis Secondary to Hand, Foot, and Mouth Disease in a Pregnant Daycare Worker

Transverse myelitis (TM) is a rare inflammatory disorder of the spinal cord that infections, vaccines, and autoimmune processes can cause or may have no discernible cause. About half of the cases are caused by an infection, usually a viral respiratory infection, flu-like illness, or sometimes a gastrointestinal infection. Although coxsackieviruses and enteroviruses are known to cause TM, it is more commonly associated with respiratory symptoms or systemic signs than a rash. In this case, we present a pregnant daycare worker who had a case of longitudinally extensive TM after an episode of hand, foot, and mouth disease (HFMD), which only showed the typical rash without fever or systemic signs.

Pediatric long-term noninvasive respiratory support in children with central nervous system disorders

RATIONALE

The use of long-term noninvasive respiratory support is increasing in children along with an extension of indications, in particular in children with central nervous system (CNS) disorders.

OBJECTIVE

The aim of this study was to describe the characteristics of children with CNS disorders treated with long-term noninvasive respiratory support in France.

METHODS

Data were collected from 27 French pediatric university centers through an anonymous questionnaire filled for every child treated with noninvasive ventilatory support ≥3 months on 1st June 2019.

MAIN RESULTS

The data of 182 patients (55% boys, median age: 10.2 [5.4;14.8] years old [range: 0.3-25]) were collected: 35 (19%) patients had nontumoral spinal cord injury, 22 (12%) CNS tumors, 63 (35%) multiple disabilities, 26 (14%) central alveolar hypoventilation and 36 (20%) other CNS disorders. Seventy five percent of the patients were treated with noninvasive ventilation (NIV) and 25% with continuous positive airway pressure (CPAP). The main investigations performed before CPAP/NIV initiation were nocturnal gas exchange recordings, alone or coupled with poly(somno)graphy (in 29% and 34% of the patients, respectively). CPAP/NIV was started in an acute setting in 10% of the patients. Median adherence was 8 [6;10] hours/night, with 12% of patients using treatment <4 h/day. Nasal mask was the most common interface (70%). Airway clearance techniques were used by 31% of patients.

CONCLUSION

CPAP/NIV may be a therapeutic option in children with CNS disorders. Future studies should assess treatment efficacy and patient reported outcome measures.

Lumbar decompression and fusion for symptomatic spinal stenosis in a patient with chronic thoracic sensory level from prior transverse myelitis: a case report

BACKGROUND

Many patients with transverse myelitis suffer from sensory loss below the spinal level of the lesion. This is commonly associated with chronic neuropathic pain. However, the presence of somatic pain below a complete thoracic sensory level after transverse myelitis is exceptionally rare, and it is unclear if surgical decompression is an effective form of treatment for these patients.

CASE PRESENTATION

In this report, we describe a 22-year-old Caucasian female who suffered from chronic lumbar back pain despite a complete thoracic sensory level secondary to prior transverse myelitis. Imaging demonstrated multilevel central stenosis below the sensory level, and her pain improved after surgical decompression. To our knowledge, this is the first reported case of symptomatic lumbar stenosis below a sensory level after transverse myelitis successfully treated with surgical decompression.

CONCLUSION

This is the first reported case of a patient with symptomatic lumbar stenosis after transverse myelitis whose lower back pain and quality of life improved following surgical decompression and fusion. This case provides evidence that typical lumbago is possible in patients with sensory loss from transverse myelitis, and standard lumbar decompression may provide benefit for these patients.

Infectious Myelopathies

OBJECTIVE

Infectious myelopathy of any stage and etiology carries the potential for significant morbidity and mortality. This article details the clinical presentation, risk factors, and key diagnostic components of infectious myelopathies with the goal of improving the recognition of these disorders and guiding subsequent management.

LATEST DEVELOPMENTS

Despite our era of advanced multimodal imaging and laboratory diagnostic technology, a causative organism often remains unidentified in suspected infectious and parainfectious myelopathy cases. To improve diagnostic capability, newer technologies such as metagenomics are being harnessed to develop diagnostic assays with a greater breadth of data from each specimen and improvements in infection identification. Conventional assays have been optimized for improved sensitivity and specificity.

ESSENTIAL POINTS

Prompt recognition and treatment of infectious myelopathy decreases morbidity and mortality. The key diagnostic tools include serologies, CSF analysis, and imaging; however clinical presentation, epidemiologic risk factors, and history of recent illness are all vital to making the proper diagnosis because current laboratory and imaging modalities are often inconclusive. The cornerstone of recommended treatment is targeted antimicrobials with appropriate immune modulation, surgical intervention, supportive care, and interdisciplinary involvement, all of which further improve outcomes for patients with infectious myelopathy.

Transverse Myelitis in the Setting of Enterobius vermicularis (Pinworm) Infection: Case Report

Myelitis is a rare inflammatory myelopathy, and known associated etiologies only account for a small number of causes. A significant percentage of cases have an unknown etiology and are considered idiopathic. With 64% to 68% of cases fitting into the idiopathic category, helminth infections, and specifically pinworm parainfections, should be considered in cases that would otherwise be classified as idiopathic. This case report outlines a pediatric patient diagnosed with myelitis given her progressive weakness, fussiness, refusal to bear weight as well as magnetic resonance imaging (MRI) demonstrating T2-hyperintense signal and/or T1 gadolinium enhancement, and/or positive cerebrospinal fluid (CSF) inflammatory markers. This patient had a negative evaluation for typical known etiologies for myelitis including no signs of multiple sclerosis and neuromyelitis optica spectrum disorder on brain MRI, oligoclonal banding and aquaporin-4 autoantibodies, and no evidence of bacterial or viral meningitis given normal cell counts and cultures in CSF. She was found to have a pinworm infection, suggesting a parasitic parainfectious etiology of her myelitis. This case outlines the first case noting the correlation between myelitis and pinworm infection in a pediatric patient.

Neurosarcoidosis and Transverse Myelitis: Life-Threatening Manifestations of Sarcoidosis

Sarcoidosis, a systemic granulomatous disorder, typically involves the lungs, skin, and lymph nodes. Neurological manifestations are diverse and may include longitudinally extensive transverse myelitis (LETM), an uncommon inflammatory disorder of the spinal cord. We present a case of a 62-year-old female with LETM as the initial manifestation of sarcoidosis. The patient exhibited progressive bilateral lower extremity weakness, urinary retention, and sensory disturbances. Diagnostic workup revealed characteristic findings on spinal magnetic resonance imaging (MRI), cerebrospinal fluid analysis, and thoracic biopsy. Treatment with high-dose corticosteroids and subsequent immunomodulatory therapy resulted in significant improvement. Our case highlights the importance of including sarcoidosis in the differentials of LETM, particularly in patients with no respiratory manifestations.

A case report of longitudinal extensive transverse myelitis: immunotherapy related adverse effect vs. COVID-19 related immunization complications

Background: Transverse myelitis (TM) is a rare, acquired neuro-immunological spinal cord disorder that occurs with rapid onset of motor weakness, sensory deficits with bowel and bladder dysfunction. Patients being treated with immune checkpoint inhibitors (ICIs) for advanced malignancy have a known higher propensity of developing neuro immune complications. With the advent of COVID-19 pandemic there have been reported cases of TM with COVID-19 immunization. The reported infrequency of TM with both of the aforementioned causes makes delineation of the etiology challenging.Methods: We present a patient with metastatic small cell lung cancer (SCLC) on maintenance Atezolizumab immunotherapy who developed longitudinal extensive transverse myelitis (LETM) after administration of second dose of COVID-19 mRNA vaccine one day prior to presenting symptoms of acute paralysis of the lower extremity, sensory loss from chest down with overflow incontinence. A clinical diagnosis of myelopathy was supported by MRI of the spine illustrating enhancing lesions from C7-T7 concerning for LETM.Results: A 5-day course of pulsed methylprednisolone followed by therapeutic plasma exchange for 3 days resulted in only minimal improvement in the neurologic exam with increased strength in his lower extremities while the sensory level remained unchanged.Conclusions: This case demonstrates the complication and symptomatology of TM in the setting of anti-PD-L1 monoclonal antibody with coincidental COVID-19 mRNA vaccine administration. The causal relationship between the vaccine and LETM is difficult to establish. However, the presence of a known inciting factor hints at a possible exaggeration of the existing neuro-inflammatory process.

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

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

A Case of Transverse Myelitis Following Treatment with Atezolizumab for Advanced Hepatocellular Carcinoma

The results of the IMbrave150 study have led to widespread use of the combination therapy of atezolizumab and bevacizumab as a first-line treatment for unresectable or metastatic hepatocellular carcinoma (HCC). Compared to traditional cytotoxic chemotherapy agents, immune checkpoint inhibitors show a spectrum of side effects ranging from mild side effects such as skin rash to potentially severe systemic effects such as myocarditis. We present a case of transverse myelitis diagnosed during the treatment of HCC with atezolizumab and bevacizumab combination therapy.

Autoimmune/inflammatory syndrome induced by adjuvants (ASIA): past, present, and future implications

Adjuvants, as the name indicates, are adjoined material aimed to assist in functioning as when added to vaccines they are meant to boost the effect and strongly stimulate the immune system. The response of the immune system can be unpredictable, and the autoimmune/inflammatory syndrome induced by adjuvants (ASIA) was developed to address possible adverse reactions of an autoimmune and inflammatory type that may be caused by adjuvants. While ASIA, as a syndrome, was coined and defined in 2011; reports describing patients with vague and nonspecific clinical symptoms following vaccinations appeared much earlier. In other words, ASIA came to define, arrange, and unite the variety of symptoms, related to autoimmunity, caused not by the vaccine itself, rather by the adjuvant part of the vaccine such as aluminum, among others. Accordingly, the introduction of ASIA enabled better understanding, proper diagnosis, and early treatment of the disorder. Furthermore, ASIA was shown to be associated with almost all body systems and various rheumatic and autoimmune diseases such as systemic lupus erythematosus, antiphospholipid syndrome, and systemic sclerosis. In addition, the correlation between COVID-19 and ASIA was noticed during the pandemic. In this review, we summarized the reported effects of adjuvants and medical literature before and after ASIA was defined, the several ways ASIA can manifest and impact different systems of the body, and the incidences of ASIA during the COVID-19 pandemic. It is important to clarify, that vaccines are among, if not the, most effective means of fighting infectious diseases however, we believe that vaccines manufacturing is not above criticism, particularly when it comes to added substances possessing a risk of side effects.

Heroin-Induced Transverse Myelitis in a Chronic Heroin User: A Case Report

Transverse myelitis is a rare but documented sequela of heroin use. While the underlying etiology is not clearly elucidated, the prevailing pathophysiologic mechanism amongst existing literature suggests an immune-mediated hypersensitivity reaction due to heroin insufflation following a long period of abstinence. Outcomes vary among the limited reports, but prognosis tends to be poor due to an acute and rapidly progressive disease course. Here, we describe a case of extensive transverse myelitis in a chronic heroin user following heroin insufflation. This report hopes to provide greater insight into the underlying cause of this rare phenomenon due to our patient's discrepancy from the documented norm of heroin abstinence preceding disease onset.

Extensive Longitudinal Transverse Myelitis in Systemic Lupus Erythematosus: Presentation of a Case and Literature Review

Acute transverse myelitis (TM) is an inflammatory disease that manifests with motor, sensory, and autonomic symptoms of rapid progression with catastrophic outcomes; the three main causes of acute TM are demyelinating diseases, infections, and autoimmune inflammatory diseases such as systemic lupus erythematosus (SLE). TM is one of the 19 neuropsychiatric diseases associated with SLE according to the American College of Rheumatology (ACR) and has been described as affecting 1 to 2% of all cases of SLE and is frequently misdiagnosed, leading to a high rate of morbidity and mortality. This report highlights the case of a 25-year-old woman with a history of SLE who consulted for a progressive decrease in lower limb strength and loss of sphincter control, accompanied by dysesthesias from the abdomen to the feet. Upon examination, she exhibited severe paraparesis and preserved myotendinous reflexes, and a sensory level at T10 was documented. A contrast-enhanced MRI of the thoracolumbar spine was performed, showing signal hyperintensity on T2 and Short Tau Inversion Recovery (STIR) from T6 to T10. These findings are compatible with TM. Given the refractory response to initial management, the use of cyclophosphamide was required. After one week of hospital treatment, the patient achieved partial neurological recovery and was discharged for continued outpatient rheumatology care. For the diagnosis of TM in patients with SLE, a high clinical suspicion is required. Recognizing and immediately addressing this condition is crucial to prevent catastrophic outcomes and the high morbidity and mortality that stem from this association.

Can Failed Back Surgery Syndrome Be Healed by Transverse Myelitis?

Failed back surgery syndrome (FBSS) is a condition characterized by persistent or recurring back pain following spinal surgery. Etiological factors for FBSS are being studied by investigators and clinicians in an attempt to organize them based on their temporal relation to the surgery event. However, many questions regarding the pathophysiology of FBSS remain, which has resulted in a lack of efficacy among its treatment options. In this report, we present a remarkable case of longitudinally extensive transverse myelitis (LETM) in a patient with a medical history of FBSS who was taking multiple pain medications but had persisting pain. The patient, a 56-year-old woman, presented with an incomplete motor injury (American Spinal Injury Association Impairment Scale D) and a neurological level of C4. Investigations revealed an idiopathic LETM that was unresponsive to high doses of corticosteroids. An inpatient rehabilitation program was initiated, resulting in favorable clinical progress. The patient no longer complained of back pain, and her pain medication was gradually discontinued. At the time of discharge, the patient was able to walk with a stick, dress and groom herself independently, and eat with an adapted fork without experiencing pain. As the pain mechanisms underlying FBSS are complex and not yet fully understood, this clinical case aims to contribute to the discussion of possible pathological mechanisms implicated in LETM that may have contributed to the shutdown of pain perception in a patient with a history of FBSS. By doing so, we hope to identify new and effective ways to treat FBSS.

Neuromyelitis Optica: A Case Report From a Radiological Perspective

Neuromyelitis optica (NMO), also known as Devic's disease, is a chronic inflammatory disorder of the optic nerve and the spinal cord. Similar to multiple sclerosis, it has a relapsing and remitting characteristic. The disease is characterized by optic neuritis and longitudinal extensive inflammation of the spinal cord. Magnetic resonance imaging (MRI) is the modality of choice for this disorder. The serological examination also shows the presence of aquaporin-4 (AQP4) autoantibodies. MRI shows longitudinal extensive transverse myelitis and signs of optic neuritis such as inflammation of the optic nerve. The treatment is based on intravenous corticosteroids with or without plasmapheresis. The current case is a 25-year-old African American male patient who presented with multiple sclerosis-like symptoms (i.e., optic neuritis and transverse myelitis) but turned out to have NMO. Serological examination reveals the absence of AQP4 autoantibodies. A radiological examination showed swelling in the cervical cord. This case report strongly focuses on the radiological findings of NMO.

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

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

Elsberg Syndrome with Mixed Presentation as Meningitis Retention Syndrome: A Pediatric Case Report and Comprehensive Review of the Literature

Elsberg syndrome is a typically infectious syndrome that may cause acute or subacute bilateral lumbosacral radiculitis and sometimes lower spinal cord myelitis. Patients often present with various neurological symptoms involving the lower extremities, including numbness, weakness, and urinary disturbances such as retention. A 9-year-old girl with no significant past medical history presented with altered mental status, fever, urinary retention, and anuria and was found to have encephalomyelitis. An extensive diagnostic workup led to ruling out possible etiologies until identifying Elsberg syndrome. In this report, we describe a case of Elsberg syndrome caused by West Nile virus (WNV). To the best of our knowledge, this is the first reported case of its kind in the pediatric population. Utilizing PubMed and Web of Science databases, we reviewed the literature to describe the neurogenic control of the urinary system in correlation to a multitude of neurologic pathologies.

Disease characteristics of idiopathic transverse myelitis with serum neuronal and astroglial damage biomarkers

Despite its close association with CNS inflammatory demyelinating disorders (CIDDs), pathogenic characteristics of idiopathic transverse myelitis (ITM) remain largely unknown. Here, we investigated serum levels of neurofilament light chain (sNfL) and glial fibrillary acidic protein (sGFAP) in patients with ITM to unravel the disease characteristics of ITM. We prospectively recruited 70 patients with ITM, 62 with AQP4 + NMOSD and 85 with RRMS-including 31 patients with acute TM attacks-along with 30 HCs. We measured sNfL and sGFAP levels using single-molecular arrays and compared these levels per lesion volume between the disease groups during attacks. Compared to HCs, ITM patients showed higher sNfL and sGFAP during acute attacks (sNfL: p < 0.001, sGFAP: p = 0.024), while those in remission (sNfL: p = 0.944, sGFAP: p > 0.999) did not, regardless of lesion extents and presence of multiple attacks. ITM patients demonstrated lower sGFAP/volume (p = 0.011) during acute attacks and lower sGFAP (p < 0.001) in remission compared to AQP4 + NMOSD patients. These findings suggest that both neuronal and astroglial damages occur in patients with acute ITM attacks at a similar level to those with RRMS, distinct from AQP4 + NMOSD. However, active neuroinflammatory process was not remarkable during remission in this cohort.

A Case of Transverse Myelitis After Moderna Severe Acute Respiratory Syndrome Coronavirus Vaccination

Transverse myelitis (TM) is an inflammatory syndrome of the spinal cord that presents with acute-to-subacute neurological deficits. The differential for TM is broad and includes demyelinating, infectious, neoplastic and paraneoplastic, autoimmune, and metabolic/toxic etiologies. With the novel severe acute respiratory syndrome coronavirus pandemic, more commonly referred to as the coronavirus infectious disease of 2019 (COVID-19), there have been increasing reports of neurological complications. In this case report, we describe a novel case of longitudinally-extensive TM associated with the Moderna vaccination.

New onset urinary incontinence in a pediatric patient with transverse myelitis

Transverse myelitis is an inflammatory disorder of the spinal cord that can present with a wide array of lower urinary tract symptoms including urinary retention, frequency, urgency, and urge incontinence. We report a case of a 15 year old male with new onset urinary incontinence who initially presented to the urologist and was subsequently diagnosed with transverse myelitis.

Transverse myelitis in children and adults

Transverse myelitis is a noncompressive myelopathy of inflammatory origin. The causes are broad, ranging from infective or toxic to immuno-mediated etiology. They can be manifestations of systemic diseases, such as sarcoidosis and systemic lupus erythematous, or phenotypes of neuroinflammation; in a portion of cases, the etiology remains unknown, leading to the designation idiopathic. The clinical presentation of transverse myelitis depends on the level of spinal cord damage and may include sensorimotor deficits and autonomic dysfunction. The age of onset of the disorder can impact the symptoms and outcomes of affected patients, with differences in manifestation and prognosis between children and adults. Spinal cord magnetic resonance imaging and cerebrospinal fluid examination are the main diagnostic tools that can guide clinicians in the diagnostic process, even though the search for antibodies that target the structural components of the neural tissue (anti-aquaporin4 antibodies and anti-myelin-oligodendrocyte antibodies) helps in the distinction among the immune-mediated phenotypes. Management and outcomes depend on the underlying cause, with different probabilities of relapse according to the phenotypes. Hence, immunosuppression is often recommended for the immune-mediated diseases that may have a higher risk of recurrence. Age at onset has implications for the choice of treatment.

A review of the potential neurological adverse events of COVID-19 vaccines

Despite the advantages of getting access to the coronavirus disease 2019 (COVID-19) vaccines, their potential ability to induce severe adverse events (AEs) has been a significant concern. Neurological complications are significant among the various adverse events following immunization (AEFI) due to their likely durability and debilitating sequelae. Neurological AEs following COVID-19 vaccination can either exacerbate or induce new-onset neuro-immunologic diseases, such as myasthenia gravis (MG) and Guillain-Barre syndrome (GBS). The more severe spectrum of AEs post-COVID19 vaccines has included seizures, reactivation of the varicella-zoster virus, strokes, GBS, Bell's palsy, transverse myelitis (TM), and acute disseminated encephalomyelitis (ADEM). Here, we discuss each of these neurological adverse effects separately.

HLA-A, HSPA5, IGFBP5 and PSMA2 Are Restriction Factors for Zika Virus Growth in Astrocytic Cells

(1) Background: Zika virus (ZIKV), an arbo-flavivirus, is transmitted via Aeges aegyptii mosquitoes Following its major outbreaks in 2013, 2014 and 2016, WHO declared it a Public Health Emergency of International Concern. Symptoms of ZIKV infection include acute fever, conjunctivitis, headache, muscle & joint pain and malaise. Cases of its transmission also have been reported via perinatal, sexual and transfusion transmission. ZIKV pathologies include meningo-encephalitis and myelitis in the central nervous system (CNS) and Guillain-Barré syndrome and acute transient polyneuritis in the peripheral nervous system (PNS). Drugs like azithromycin have been tested as inhibitors of ZIKV infection but no vaccines or treatments are currently available. Astrocytes are the most abundant cells in the CNS and among the first cells in CNS infected by ZIKV; (2) Methods: We previously used SOMAScan proteomics to study ZIKV-infected astrocytic cells. Here, we use mass spectrometric analyses to further explain dysregulations in the cellular expression profile of glioblastoma astrocytoma U251 cells. We also knocked down (KD) some of the U251 cellular proteins using siRNAs and observed the impact on ZIKV replication and infectivity; (3) Results & Conclusions: The top ZIKV dysregulated cellular networks were antimicrobial response, cell death, and energy production while top dysregulated functions were antigen presentation, viral replication and cytopathic impact. Th1 and interferon signaling pathways were among the top dysregulated canonical pathways. siRNA-mediated KD of HLA-A, IGFBP5, PSMA2 and HSPA5 increased ZIKV titers and protein synthesis, indicating they are ZIKV restriction factors. ZIKV infection also restored HLA-A expression in HLA-A KD cells by 48 h post-infection, suggesting interactions between this gene product and ZIKV.

Transverse myelitis following COVID-19: Insights from a multi-center study and systematic literature review

INTRODUCTION

We aimed to provide insights into transverse myelitis (TM) following COVID-19 by analyzing cases treated at tertiary care neurology centers and a systemic review of the literature.

METHODS

The retrospective observational multi-center study was conducted at the four university neurology departments in Croatia, Slovenia, Serbia, and Austria. We searched for acute myelitis cases that occurred during or after COVID-19. A systemic review of the literature on COVID-19 and transverse myelitis was performed.

RESULTS

We identified 76 persons with TM associated with COVID-19, 13 from the multi-center study and 63 from the literature review. Most of the participants (55.6%) had an intermediate latency, 25.4% had short and 19% long latency from COVID-19 symptoms to TM. The clinical presentation consisted of the typical TM signs. More than half of the participants had inflammatory changes in the CSF, with rare patients having intrathecal OCB synthesis and positive serology for anti-MOG or anti-AQP4 antibodies. Persons with autonomic symptoms and CSF pleocytosis were significantly more common to have an intermediate latency of 8 to 21 days from COVID-19 to TM (p = 0.005 and p = 0.003; respectively). According to logistic regression analysis, only participants with lesions evident on spinal cord MRI compared to normal spinal cord MRI had reduced risks for poor recovery. >80% of participants were treated with a combination of corticosteroids and intravenous immunoglobulins or plasma exchange with 73% having incomplete recovery.

CONCLUSION

Our study further characterizes clinical, laboratory, and MRI features, as well as treatment of TM associated with COVID-19.

Lethargy and quadraparesis as initial manifestations of covid-19 child: Case report

Introduction

and importance: SARS-CoV-2 infection classically presents with fever and respiratory illness. However, neurological manifestations are also being reported in the literature. Transverse myelitis is caused by inflammation of spinal cord. There are various possible etiologies for this neurologic condition that include viral or bacterial infections.

Case presentation

We present a case of 2 –year-old female complained of weakness of all four limbs and lethargy.She was febrile(39), respiratory rate 30/min and oxygensaturation of 89% on room air. Neurological examination revealed intact cranial nerves, GCS of 14/15 and upper and lower limbs weakness with medical research council(MRC) score of 2/5 Sensory examination showed decreased sensation of all modalities in lower limbs with a sensory level at T4.

Clinical discussion

Laboratory results and cerebrospinal fluid (CSF) analysis showed normal values. Brain MRI was normal. An urgent Gadolinium-enhanced magnetic resonance imaging of the whole spine was done and revealed extensive diffuse hyper intense signal involving predominantly the grey matter of the upper cervical spinal cord. Mild enlargement and swelling of the cervical cord were also note. She was given pulse doses of IV methylprednisolone 30mg/kg followed by oral prednisolone for 40 days. She was also given IV gamma globulin 400mg/kg for five days. A marked improvement of his neurological deficit was noted over a period of 16 days after treatment.

Conclusion

when a patient with myelopathy is systemically ill with fever andloss of consciousness, prompt investigation of the causative agent is needed for appropriate management. Even after the pandemic Status; COVID-19 should be considered a differential diagnosis in patients presenting with loss of consciousness, ataxia, convulsions, motor deficits, encephalitis, myelitis, or neuritis.

Clinical and Imaging Characteristics of Non-Neoplastic Spinal Lesions: A Comparative Study with Intramedullary Tumors

The features of non-neoplastic lesions are often similar to those of intramedullary tumors, and a differential diagnosis is challenging to obtain in some cases. A surgical biopsy, which is performed on highly invasive tumors, should be avoided in cases of non-neoplastic lesions. Therefore, an accurate diagnosis is important prior to treatment. We evaluated 43 patients suspected of having spinal cord tumors and, finally, were diagnosed with non-neoplastic intramedullary lesions via magnetic resonance imaging. The patients commonly presented with myelitis. The patients with non-neoplastic neurological diseases had a significantly shorter symptom duration than those with intramedullary astrocytomas. The proportion of patients with non-neoplastic neurological diseases who presented with lesions at the cervical spinal level and focal lesions on axial imaging but without a spinal cord enlargement was significantly higher than that of patients with intramedullary astrocytomas. The current study aimed to distinguish spinal cord tumors from non-neoplastic intramedullary lesions based on their distinct features.

Nontraumatic Spinal Cord Injury: Epidemiology, Etiology and Management

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.

Thoracic epidural arteriovenous malformation causing rapidly progressive myelopathy and mimicking an acute transverse myelitis: A case report

Clinical symptoms of spinal arteriovenous malformations (AVMs) combined with acute spontaneous hemorrhage lack specificity, which leads to misdiagnosis and delays treatment. The current study aimed to analyze the causes of misdiagnosis and review the key points of diagnosis and treatment. We presented an extremely rare case of a 25-year-old man whose clinical characteristics mimicked acute transverse myelitis, suffering from rapidly and repeatedly progressive myelopathy with a mass. The pathological diagnosis of the mass was AVM; symptom-based surgical treatment with posterior decompression and the removal of epidural AVMs during the postoperative 12-month follow-up period were performed. The manual muscle testing grade score of the proximal and distal muscles in both lower limbs improved from 1 to 5, and the American Spinal Injury Association motor and sensation grade score improved from B to E. In the case of sudden or progressive spinal cord injury of unknown cause and acute spinal cord dysfunction, there might be a misdiagnosis. The key to a differential diagnosis is to take into account AVMs, and spontaneous hemorrhages and hematomas should also be suspected. Angiography and magnetic resonance imaging are very important for the diagnosis of AVM, and we hope to enhance clinicians' understanding of and vigilance for such diseases.

COVID-19-associated transverse myelitis treated by therapeutic plasma exchange: A case report

BACKGROUND

Transverse myelitis (TM) is a very uncommon condition in children which can be associated with viral infections. Acute TM cases have been reported after Coronavirus disease 2019 (COVID-19) infection during the pandemic.

CASE REPORT

We report a child with TM related to severe acute respiratory syndrome coronavirus 2, who was successfully treated with therapeutic plasma exchange (TPE). Inability to walk and urinary retention were the central nervous system symptom. Spinal magnetic resonance imaging revealed signal changes in the spinal cord. Her neurological symptoms worsened despite receiving IVIG and high-dose steroids for the first 3 d. We performed 10 TPE sessions with 5% albumin replacement and the neurological symptoms rapidly improved.

CONCLUSION

We demonstrated that a child diagnosed with acute TM related to COVID-19 infection, was successfully treated with TPE.

Transverse Myelitis in Naloxone Reversible Acute Respiratory Failure-A Case Report

Transverse myelitis (TM) is a rare inflammatory myelopathy presenting as bilateral neurologic deficit localized to the spinal cord. A critical management step in the emergency department (ED) is evaluating for and treating acute reversible causes such as mass lesion or reversible ischemia when present. Described in this case report is TM presenting after a respiratory arrest in suspected opioid overdose. Magnetic resonance imaging (MRI), ideally with contrast, and lumbar puncture are essential diagnostic studies to confirm inflammation. Finally, further diagnostic efforts are aimed at evaluation and treatment for other concurrent illnesses.

Topics

Transverse myelitis, transverse myelopathy, hypoxia, opioid overdose, hypoxic spinal cord injury.

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

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