Cytomegalovirus-associated transverse myelitis in a non-immunocompromised patient

Identifying specific myelopathy etiologies in the evaluation of suspected myelitis: A retrospective analysis

BACKGROUND

Myelopathies require prompt etiologic diagnosis. We aimed to identify a specific myelopathy diagnosis in cases of suspected myelitis to highlight clinicoradiologic differences.

METHODS

In this retrospective, single-centre cohort of subjects with suspected myelitis referred to London Multiple Sclerosis (MS) Clinic between 2006 and 2021, we identified those with MS and reviewed the remaining charts for etiologic diagnosis based on clinical, serologic, and imaging details.

RESULTS

Of 333 included subjects, 318/333 (95.5%) received an etiologic diagnosis. Most (274/333, 82%) had MS or clinically isolated syndrome. Spinal cord infarction (n = 10) was the commonest non-inflammatory myelitis mimic characterized by hyperacute decline (n = 10/10, 100%), antecedent claudication (n = 2/10, 20%), axial owl/snake eye (n = 7/9, 77%) and sagittal pencillike (n = 8/9, 89%) MRI patterns, vertebral artery occlusion/stenosis (n = 4/10, 40%), and concurrent acute cerebral infarct (n = 3/9, 33%). Longitudinal lesions were frequent in aquaporin-4-IgG-positive neuromyelitis optica spectrum disorder (AQP4+NMOSD) (n = 7/7, 100%) and myelin oligodendrocyte glycoprotein-IgG-associated disorder (MOGAD) (n = 6/7, 86%), accompanied by bright spotty (n = 5/7, 71%) and central-grey-restricted (n = 4/7, 57%) T2-lesions on axial sequences, respectively. Leptomeningeal (n = 4/4, 100%), dorsal subpial (n = 4/4, 100%) enhancement, and positive body PET/CT (n = 4/4, 100%) aided the diagnosis of sarcoidosis. Spondylotic myelopathies had chronic sensorimotor presentations (n = 4/6, 67%) with relative bladder sparing (n = 5/6, 83%), localizable to sites of disc herniation (n = 6/6, 100%). Metabolic myelopathies showed dorsal column or inverted 'V' sign (n = 2/3, 67%) MRI T2-abnormality with B12 deficiency.

CONCLUSIONS

Although no single feature reliably confirms or refutes a specific myelopathy diagnosis, this study highlights patterns that narrow the differential diagnosis of myelitis and facilitate early recognition of mimics.

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

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

Infectious Myelopathies

PURPOSE OF REVIEW

This article reviews infectious etiologies of spinal cord dysfunction, emphasizing the importance of recognizing common clinicoradiographic syndromes and interpreting them in the context of exposure risk and individual host susceptibilities.

RECENT FINDINGS

This article discusses the shifting spectrum of neurologic infectious diseases, the growing population of patients who are immunocompromised, and the emergence of effective antiretroviral therapies. In addition, it discusses new molecular and serologic tests that have the potential to enhance our ability to rapidly and accurately diagnose infectious diseases of the spine.

SUMMARY

When evaluating patients with suspected infectious myelopathies, it is imperative to narrow the range of pathogens under consideration. The geography, seasonality, and clinicoradiographic presentation and immunocompetence status of the patient define the range of potential pathogens and should guide testing and initial management.

High-dose corticosteroids for acute cytomegalovirus-associated transverse myelitis in the immunocompetent patient: a case report and systematic review

We present an immunocompetent patient with transverse myelitis (TM) during acute cytomegalovirus (CMV) infection, as evidenced by a reactive serum CMV IgM and CMV viremia. The patient had an excellent outcome after receiving only high-dose methylprednisolone. Given concerns that practitioners may have around the use of immunosuppressive therapy for this potentially infectious myelopathy, we systematically reviewed the literature to assess outcomes after administration of high-dose corticosteroids to this population. Despite severe disease at clinical nadir with inability to ambulate, immunocompetent patients with acute CMV-associated TM who received high-dose corticosteroids had good clinical outcomes 1 month to 1 year after presentation.

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

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

Cytomegalovirus-related transverse myelitis in an immunocompetent host: a subacute onset of an immune-mediated disease?

We report a case of transverse myelitis in an immunocompetent host with an atypical long onset of symptoms. A 56-year-old man was admitted to the hospital reporting 5 months of progressive ascending lower extremity weakness and numbness, inability to walk, bowel incontinence,urinary retention and several episodes of nausea and vomiting. MRI showed moderate spinal swelling and multiple hyperintense signal changes on cervical levels C2-C5 and thoracic levels T1-T3. Cerebrospinal fluid (CSF) showed pleocytosis and was positive for anti-cytomegalovirus (CMV) IgG intrathecal antibodies, but the CSF PCR for CMV was negative. The diagnosis of immune-mediated CMV-related transverse myelitis was established and the patient was treated with methylprednisolone and valgancyclovir. The patient had poor recovery and remained paraplegic at discharge.

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

Background

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

Case presentation

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

Conclusion

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

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

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

Tissue and cell-specific transcriptional activity of the human cytomegalovirus immediate early gene promoter (UL123) in zebrafish

The human cytomegalovirus (CMV) is a member of the herpesvirus superfamily and causes different diseases including encephalitis, gastrointestinal diseases, pneumonitis, hepatitis, and retinitis. The immediate early (IE) gene of the human cytomegalovirus is essential to the viral replication. The proximal promoter region of this gene behaves as a strong enhancer and was commonly used to overexpress genes in vitro and in vivo in numerous cell types and species. However, there was no detailed report on the spatial and temporal transcriptional activity of the human CMV-IE gene promoter in zebrafish. In the present study, we generated stable transgenic zebrafish lines carrying the eGFP reporter gene under the control of the human CMV-IE gene promoter (-602/-14). We demonstrated that the hCMV-IE:eGFP transgene was expressed in numerous tissues but transgene expression was either regionalized or restricted to specific cell types as embryo and larval development progressed. In adult, the global expression pattern was similar but not identical to that described for the simian CMV-IE gene promoter in stable zebrafish with high transgene expression in the spinal cord, olfactory organs, central nervous system, neuromasts, retina, and skeletal muscles. However, we describe additional major expression sites in the hepatocytes, the epithelial cells of the intestine, the epithelial cells of the renal tubules, and the oocytes. Interestingly, our study shows that the tissue and cell specific expression pattern of the human CMV-IE gene promoter is rather well conserved in stable transgenic zebrafish compared to that observed in mouse. The major expression sites described in zebrafish are in agreement with the targeted cells and symptoms resulting from CMV infections in human. Finally, the hCMV:eGFP transgenic lines described in the present study will be valuable tools to trace specific cell lineages in adult zebrafish.

Cytomegalovirus infections

Human cytomegalovirus, a human herpesvirus, remains a major cause of neurological disorders as a consequence of infections acquired in utero or postnatally. This article summarizes current information regarding the epidemiology, clinical manifestations, treatment, and prevention of this ubiquitous human infection.

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

Background

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

Case report

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

Conclusion

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

Neuroimaging in acute transverse myelitis

Transverse myelitis is an acute inflammatory condition. A relatively rare condition, the diversity of causes makes it an important diagnostic challenge. An approach to the classification and work-up standardizes diagnostic criteria and terminology to facilitate clinical research, and forms a useful tool in the clinical work-up for patients at presentation. Its pathogenesis can be grouped into four categories. Imaging appearances can be nonspecific; however, the morphology of cord involvement, enhancement pattern, and presence of coexistent abnormalities on MR imaging can provide clues as to the causes. Neuroimaging is important in identifying subgroups that may benefit from specific treatment.

Primary HIV infection with acute transverse myelitis

Primary HIV infection (PHI) is associated with various neurological disorders. However, acute transverse myelitis (ATM) complicating PHI has not been reported after the introduction of the combination antiretroviral therapy (cART). We encountered one patient with known PHI with clinical presentation of ATM. Treatment with cART and corticosteroids successfully improved symptoms, and no recurrence was noted after discontinuation of cART. In conclusion, concurrent use of cART and corticosteroids was effective against PHI accompanied by ATM and could be withdrawn after improvement of ATM.

Myélite à cytomégalovirus chez un adulte immunocompétent

INTRODUCTION

Cytomegalovirus (CMV) infection occurs in 40 to 100% of general population. It is often asymptomatic in immunocompetent subject but may induce neurological syndromes such as encephalitis and myelitis.

CASE RECORD

We reported a case of a 64-years-old woman immunocompetent, with acute proximal upper and lower limb weakness, paresthesias and two episodes of urinary retention. MRI of the spine showed abnormal enhancement from cervical to lumbar spine indicative for myelitis. Diagnosis of CMV associated myelitis was confirmed by a positive CMV serology. Administration of ganciclovir was followed by a partial improvement in five months.

DISCUSSION

Few cases of CMV acute myelitis in immunocompetent patients have been reported in the literature. The pathogenesis is not well known, however, immune-mediated central nervous system damage may be attributed to the pathogenesis of the disease. Early diagnosis and treatment improves the prognosis.

Neuroimaging of infections

Neuroimaging plays a crucial role in the diagnosis and therapeutic decision making in infectious diseases of the nervous system. The review summarizes imaging findings and recent advances in the diagnosis of pyogenic brain abscess, ventriculitis, viral disease including exotic and emergent viruses, and opportunistic disease. For each condition, the ensuing therapeutic steps are presented. In cases of uncomplicated meningitis, cranial computed tomography (CT) appears to be sufficient for clinical management to exclude acute brain edema, hydrocephalus, and pathology of the base of skull. Magnetic resonance imaging (MRI) is superior in depicting complications like sub-/epidural empyema and vasculitic complications notably on FLAIR (fluid-attenuated inversion recovery)-weighted images. The newer technique of diffusion-weighted imaging (DWI) shows early parenchymal complications of meningitis earlier and with more clarity and is of help in differentiation of pyogenic abscess (PA) from ring enhancing lesions of other etiology. Proton magnetic resonance spectroscopy (PMRS) seems to produce specific peak patterns in cases of abscess. The presence of lactate cytosolic amino acids and absence of choline seems to indicate PA. Also in cases of suspected opportunistic infection due to toxoplasma DWI may be of help in the differentiation from lymphoma, showing no restriction of water diffusion. In patients with herpes simplex and more exotic viruses like West Nile and Murray Valley virus DWI allows earlier lesion detection and therapeutic intervention with virustatic drugs.

Encephalomyelitis following mumps

STUDY DESIGN

A case report with review of literature since 1961.

SETTING

Departments of Neurology and Radiology, Faculty of Medicine, Zonguldak Karaelmas University, Zonguldak, Turkey.

METHOD

A 22-year-old male patient diagnosed and treated as mumps encephalomyelitis is described. The clinical findings of the patient and the difficulties in differential diagnosis are discussed with the help of previously reported eight adult cases.

RESULTS

Increased T2 signals in the spinal cord from C4 to C6 and T5 to T10 were seen by magnetic resonance imaging. This was the largest spinal involvement in the reported mumps cases. He was treated with supportive therapy oral steroids and early rehabilitation. On the sixth month, his neurological examination revealed bilateral 2/5 paresis in lower extremities.

CONCLUSION

Encephalomyelitis following mumps is an uncommon but serious event in adults.

Cytomegalovirus-associated acute transverse myelitis in immunocompetent adults

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