Diagnosis and management of acute myelopathies

The Role of MRI in Differentiating Demyelinating and Inflammatory (not Infectious) Myelopathies

Demyelinating and inflammatory myelopathies represent a group of diseases with characteristic patterns in neuroimaging and several differential diagnoses. The main imaging patterns of demyelinating myelopathies (multiple sclerosis, neuromyelitis optica spectrum disorder, acute disseminated encephalomyelitis, and myelin oligodendrocyte glycoprotein antibody-related disorder) and inflammatory myelopathies (systemic lupus erythematosus-myelitis, sarcoidosis-myelitis, Sjögren-myelitis, and Behçet's-myelitis) will be discussed in this article, highlighting key points to the differential diagnosis.

Radiological approach to non-compressive myelopathies

Background

Myelopathy, a pathological condition related to the spinal cord can broadly be categorized into compressive and non-compressive aetiologies. Magnetic resonance imaging remains the modality of choice when suspecting non-compressive myelopathy as it helps to localize the affected segment and exclude compression as the cause of myelopathy. This review deals with the imaging approach for non-compressive myelopathies.

Main body

Demyelinating disorders are the most common cause of non-compressive myelopathy and often show confounding features. Other causes include inflammatory, ischemic, metabolic, and neoplastic disorders. Non-compressive myelopathy can broadly be classified into acute and non-acute onset which can further be categorized according to the distribution of the signal abnormalities, including length of cord involvement, specific tract involvement, enhancement pattern, and the region of the spinal cord that is affected.

Conclusions

Imaging plays a critical role in the evaluation of clinically suspected cases of myelopathy and MR imaging (with or without contrast) remains the preferred modality. Compressive causes must be excluded as a cause of myelopathy. Despite a multitude of causes, the most common imaging appearance is a nonspecific T2 hyperintense signal in the spinal cord, and thus, a pragmatic diagnostic approach along with appropriate clinical and biochemical correlation is essential for arriving at an accurate diagnosis.

Non-traumatic acute myelopathies: Clinical and imaging features in a real world emergency setting

OBJECTIVE

The aetiologic diagnosis of non-traumatic acute myelopathies (AMs), and their differentiation from other mimicking conditions (i.e. 'mimics'), are clinically challenging, especially in the emergency setting. Here, we sought to identify: (i) red flags suggesting diagnoses alternative to AMs and (ii) clinical signs and magnetic resonance imaging (MRI) features differentiating non-compressive from compressive AMs.

MATERIALS AND METHODS

We retrospectively retrieved MRI scans of spinal cord dictated at emergency room from January 2016 to December 2020 in the suspicion of AMs. Patients with traumatic myelopathies and those with subacute/chronic myelopathies (i.e. MRI scans acquired >48 h from symptom onset) were excluded from analysis.

RESULTS

Our search retrieved 105 patients; after excluding 16 cases of traumatic myelopathies and 14 cases of subacute/chronic myelopathies, we identified 30 cases with non-compressive AMs, 30 cases with compressive AMs and 15 mimics. The presence of pyramidal signs (p = 0.012) and/or pain (p = 0.048) correctly identified 88% of cases with AMs. We failed to identify clinical indicators for distinguishing non-compressive and compressive AMs, although cases with inflammatory AMs were younger than cases with all the remaining conditions (p < 0.05). Different MRI patterns could be described according to the final diagnosis: among non-compressive AMs, inflammatory lesions were more often posterior or central; vascular malformation had a fairly widespread distribution; spine ischaemia was more often central. Anterior or lateral compression were more often associated with neoplasms and disc herniation , whereas hemorrhages and infections produced spine compression on all sides.

CONCLUSION

We propose a simple clinical indicator (i.e. pyramidal signs and/or pain) to distinguish AMs from their mimics in an emergency setting. Urgent spinal cord MRI remains essential to discriminate compressive and non-compressive aetiologies.

Case report: Dueling etiologies: Longitudinally extensive spinal cord lesion mimicking spinal cord infarct with simultaneous positive Lyme serology and amphiphysin antibody

Background

Longitudinally extensive spinal cord lesions are challenging diagnostic entities as they are uncommon, but various etiologies can cause them.

Case report

We report a case of a 55-year-old man with a past medical history of hypertension. He is an ex-smoker. He presented with chest pain, followed by right lower limb weakness, preceded by 2 weeks of constipation and voiding dysfunction. The examination revealed right lower limb mild flaccid paresis, absent reflexes, reduced anal tone, and urinary retention. His symptoms deteriorated over 24 h, and he developed severe flaccid paraparesis with impaired pinprick sensation below the T4 level. MRI spine showed an abnormal, non-enhancing signal in the anterior aspect of the spinal cord extending from the T4 level to the conus without associated edema. He was commenced on intravenous steroids and had significant improvement after one dose. The imaging was felt to be consistent with spinal cord infarction, and aspirin was started. The cerebrospinal fluid analysis showed elevated protein (0.8 mg/ml). Investigations for stroke and autoimmune pathologies were negative. The Lyme immunoblot confirmed intrathecal production of IgG to Borrelia antigens. The patient was started on ceftriaxone. The paraneoplastic screen identified amphiphysin antibodies. CT-TAP and PET-CT did not identify occult malignancy. The patient had a significant improvement over 2 months, strength was almost fully recovered, and autonomic functions returned to normal.

Conclusion

We describe an unusual steroid-responsive, longitudinally extensive spinal cord lesion with radiological features of spinal cord infarct and a simultaneous finding of intrathecal Lyme antibodies and serum amphiphysin antibodies.

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

OBJECTIVES

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

STUDY DESIGN

Retrospective study.

SETTING

A tertiary rehabilitation hospital.

PARTICIPANTS

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

OUTCOME MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

Acute transverse myelitis in an adult-patient with underlying ulcerative colitis: a case report

BACKGROUND

Ulcerative colitis (UC) is an idiopathic inflammatory bowel disease that limits to colon mucosa, which characterised by relapsing and remitting abdominal pain and diarrhea. Neurological complications in UC patients are usually underestimated. The most frequently reported neurological disorders associated with UC are peripheral neuropathy, cerebrovascular disease and demyelinating disease. However, acute transverse myelitis (TM) is rarely reported in UC patients.

CASE PRESENTATION

We report a case of a 39-year-old man presented with fatigue, muscle weakness, numbness in the lower limbs and fingers with underlying UC. Laboratory results revealed elevated neutrophil count, high-sensitivity C-reactive protein and erythrocyte sedimentation rate. Strip-shaped high signal intensity was identified in the cervical and thoracic spinal cord on T2-weighted magnetic resonance imaging. Acute TM was diagnosed. Significant improvements after intravenous high-dose methylprednisolone were observed.

CONCLUSION

We speculate that acute TM may be the extraintestinal manifestation of UC, which may be related to the abnormalities of cell-mediated and humoral immunity rather than the side effect of mesalazine.

Extensive Longitudinal Transverse Myelitis after Influenza A Virus Infection in a Patient with Systemic Lupus Erythematosus

Transverse myelitis (TM) is a rare complication seen in 1–2% of patients with systemic lupus erythematosus (SLE). Viral infections may cause TM in these patients by causing a dysregulation of their immune system. We report a 30-year-old woman with SLE who had influenza A and a few days later developed urinary retention, bilateral lower extremity paralysis, upper extremity weakness, and optic nerve and macular edema. Magnetic resonance imaging showed C4-T12 hyperintense lesions consistent with TM. She was treated with intravenous methylprednisolone 1 g daily for 3 days and then 6 cycles of monthly intravenous cyclophosphamide. This treatment was followed by oral prednisone. She had a remarkable clinical response. Visual acuity improved to her baseline, and muscle strength almost fully recovered. Clinicians should be aware that viral infections, including influenza, may induce TM. This case highlights the importance of early recognition and prompt treatment with immunosuppressive drugs in such cases.

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

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

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

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

Infection-Related Myelopathies

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

Myelopathy in sickle cell disease: a case-oriented review

INTRODUCTION

Although neurological complications are well recognized in patients with sickle cell disease, myelopathy has been rarely described, with few reported cases of compressive and ischemic myelopathy. We present the first case report of longitudinally extensive myelitis (LETM) in SCD and review the differential diagnosis of myelopathy in these patients.

CASE PRESENTATION

We report the case of a 29-year-old African-Brazilian man with SCD, who experienced a subacute flaccid paraparesis, with T2 sensory level and urinary retention. Cerebrospinal fluid analysis showed a lymphocytic pleocytosis and increased protein levels. MRI disclosed a longitudinally extensive spinal cord lesion, with a high T2/STIR signal extending from C2 to T12. We searched Medline/PubMed, Embase, Scopus, and Google Scholar databases for myelopathy in SCD patients.

DISCUSSION

Spinal cord compression by vertebral fractures, extramedullary hematopoietic tissue, and Salmonella epidural abscess have been reported in SCD. We found only three case reports of spinal cord infarction, which is unexpectedly infrequent compared to the prevalence of cerebral infarction in SCD. We found only one case report of varicella-zoster myelitis and no previous report of LETM in SCD patients. Specific and time-sensitive causes of myelopathy should be considered in SCD patients. In addition to compression and ischemia, LETM is a possible mechanism of spinal cord involvement in SCD patients.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

LITERATURE REVIEW

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

CONCLUSIONS

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

Acute Blindness as a Complication of Severe Acute Respiratory Syndrome Coronavirus-2

Several neurological manifestations can occur in the acute phase or in post-infection severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In certain cases, they can even reveal the disease. Although some may be consequences of direct cellular viral invasion, many represent post-infectious inflammation mediated by autoimmune mechanisms. We report the case of a 60-year-old woman who was initially consulted for acute blindness without optic neuritis. Brain MRI revealed nonspecific demyelinating lesions without any radiological signs of optic neuritis. The patient underwent an exhaustive assessment and then the diagnosis of optic neuritis with a normal orbital MRI following a SARS-CoV-2 infection was reached.

Atypical presentation of transverse myelitis in the emergency department

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

Acute transverse myelitis after SARS-CoV-2 infection: a rare complicated case of rapid onset paraplegia

A 63-year-old Caucasian male, known case of controlled type 2 diabetes, chronic renal failure, and ischemic heart disease, was presented with weakness and loss of movement in lower limbs, an absent sensation from the chest below, constipation, and urinary retention. About 4 days before these symptoms, he experienced a flu-like syndrome. Suspicious for COVID-19, his nasopharyngeal specimen’s reverse transcription-polymerase chain reaction (RT-PCR) resulted positive. Chest X-ray and HRCT demonstrated severe pulmonary involvement. Immediately, he was admitted to the emergency ward, and the treatment was started according to the national COVID-19 treatment protocol. Subsequently, diagnostic measures were taken to investigate the patient’s non-heterogeneous peripheral (spinal) neuromuscular manifestations. Brain CT scan and MRI were normal, but spinal MRI with gadolinium contrast showed extensive increased T2 signal involving central gray matter and dorsal columns, extended from C7 to T12 with linear enhancement in the sagittal plane, posteriorly within the mid and lower thoracic cord. The CSF specimen demonstrated pleocytosis, positive RT-PCR for SARS-CoV-2, and elevated IgG index. Clinical presentation, MRI, CSF, and laboratory findings prioritized the acute transverse myelitis (ATM) as a probable complication of COVID-19 infection over other differential diagnoses. Intravenous methylprednisolone and, subsequently, IV human immunoglobulin were added to the treatment regimen. In the end, the complete resolution of dysesthesia, urinary retention, and constipation were achieved. After continuous and extended respiratory and motor rehabilitation programs, he was discharged asymptomatic.

Spectrum of Myelitis in Systemic Lupus Erythematosus: Experience from a Single Tertiary Care Centre over 25 Years

BACKGROUND

Inflammatory myelitis rarely occurs in Systemic Lupus Erythematosus (SLE).

METHODS

Medical records from a tertiary care centre in India (1989-2018) were reviewed to identify patients with myelitis in SLE and their clinical characteristics and outcomes were compared with two matching comparators drawn from adjacent hospital registration numbers in the SLE database.

RESULTS

Ten patients had myelitis from a cohort of 1768 patients with SLE. Myelitis was the first manifestation of lupus in 7 (70%). Cervicothoracic cord was most frequent site of involvement. ANA was negative at onset in 2 cases. One of 4 was positive for Anti-Aquaporin 4 antibody. Four had relapsing disease (16 events) with a median time to relapse of 0.65 years (0.3- 7 years). All cases received steroid sparing agents over the follow-up duration (78.5 patient years). Lupus nephritis (20% vs. 75%, p=0.004) and haematologic manifestations (0 vs. 25%, p=0.02) were less common. Higher frequency of anti-Ro antibodies was noted in the group with myelitis (p=0.05).

CONCLUSION

Myelitis can be a presenting feature of SLE with lupus nephritis and hematologic involvement being rare. Relapses are common that mandate long-term immunosuppression.

Synchronous Occurrence of Guillain-Barre Syndrome and Transverse Myelitis of Unknown Etiology in an Adolescent

Synchronous occurrence of Guillain-Barre syndrome (GBS) and acute transverse myelitis (ATM) happens very rarely in childhood. Only a few cases of these conditions occurring simultaneously have been reported and represent a diagnostic challenge. We describe a case of a 17-year-old male presenting with acute onset of bilateral symmetrical numbness and tingling starting in the feet that rapidly ascended to the legs with associated motor weakness, associated with a sensory level and urinary retention. Albuminocytologic dissociation on cerebrospinal fluid (CSF) analysis was consistent with GBS. MRI spine revealed an area of increased T2 signal involving the dorsal aspect of the left side of the cord at the C7 level. The patient was treated with IV methylprednisolone and IV immunoglobulin with significant improvement. This report emphasizes the rarity of this synchronous occurrence in children and the need for further reports to understand the mechanism and better treatment approaches.

CNS inflammatory demyelinating disorders: MS, NMOSD and MOG antibody associated disease

Although Multiple Sclerosis is the most common central nervous system (CNS) inflammatory demyelinating disorder, other CNS inflammatory disorders should be included as diagnostic considerations. Neuromyelitis Optica Spectrum Disorder (NMOSD) and myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease are less common but share some clinical characteristics, such as optic neuritis and myelitis, which can make a specific diagnosis challenging. However, these disorders have distinctive and generally different clinical phenotypes, prognosis and management. It is imperative to distinguish each from one another, especially since the treatments (not discussed in this review) can be different. The advent of reliable testing for anti-aquaporin-4 for NMOSD and anti-MOG antibodies has helped significantly; however, diagnosis can remain challenging, especially in sero-negative cases. Clinical indicators are important to guide diagnostic work-up. Careful review of the history, neurological exam, imaging, and/or spinal fluid results are essential to making an accurate diagnosis. In this review, we will examine the clinical presentation, diagnosis, and natural history of these inflammatory CNS disorders.

A Rare Case of Acute Transverse Myelitis (ATM) and Acute Motor and Sensory Axonal Neuropathy (AMSAN) Overlap

Concomitant acute transverse myelitis (ATM) and Guillain-Barre syndrome (GBS) is described as GBS and ATM overlap. Its presentation varies greatly, thus making the diagnosis difficult. Overlap syndrome is more commonly associated with acute motor axonal neuropathy (AMAN) subtype of GBS. However, we present a case of a middle-aged gentleman with combined ATM and acute motor and sensory axonal neuropathy (AMSAN) subtype of GBS. This combination is quite rare, and only a few cases have been reported so far.

Clinical features and prognosis of patients with Guillain-Barré and acute transverse myelitis overlap syndrome

OBJECTIVES

Patients who present with Guillain-Barré syndrome (GBS) and acute transverse myelitis (ATM), either simultaneously or consecutively, are defined as having GBS/ATM overlap syndrome. As this syndrome has been underinvestigated, we performed a literature review to evaluate case reports of GBS/ATM overlap syndrome to facilitate its early diagnosis.

PATIENTS AND METHODS

We searched four scientific literature databases (PUBMED, EMBASE, ELSEVIER and WEB OF SCIENCE) for cases that presented as GBS/ATM overlap syndrome. Eighteen articles that described 23 cases were included, and the clinical and prognostic data were analyzed.

RESULTS

Initially, only five (29.4%) patients were diagnosed with GBS/ATM overlap syndrome. Patients with GBS/ATM overlap syndrome presented as four clinical features. First, some of the patients displayed abnormal pyramidal signs, including 29.4% of patients who had positive pyramidal signs or a negative plantar reflex and 17.6% of patients who had signs of areflexia or hyporeflexia combined with positive pyramidal signs. Second, patients suffered pain and respiratory failure at a high rate (43.5% with pain at the onset of the disease, 43.5% with ventilator support, and 47.8% shown with respiratory failure). Third, patients had a partial clinical recovery of immunomodulators, 56.5% of patients had a favorable outcome, 46.2% of patients who received intravenous immunoglobulin (IVIG) combined steroids responded well to the treatment. Four, acute axonal polyneuropathy seemed to be associated with poor outcomes (odds ratio = 3.00, 95% CI = 1.35-6.68, P = 0.01). Abnormalities in spinal cord magnetic resonance imaging (MRI) were detected in all patients, and the most frequently involved segments were the cervical cord (69.6%) and the thoracic cord (69.6%). In addition to spinal cord lesions, in three patients lesions in the medulla and cerebral hemisphere were also observed. The most common prescriptions included a high dose of methylprednisolone at 1 g/day for 3-5 days that was followed by a 6-week course of oral prednisone and IVIG at 0.4 g/kg/day for 5 days.

CONCLUSION

While it is difficult to make an early diagnosis of GBS/ATM overlap syndrome, electrophysiology is helpful in the diagnosis of GBS and spinal cord MRIs are key to identifying ATM. Brain MRIs are also recommended to detect subclinical lesions. The combined use of IVIG and steroids was the most frequent treatment. However, less than half of the patients responded positively to treatment. Acute axonal neuropathy may be a risk factor for a poor prognosis.

Systemic lupus erythematosus: a case-based presentation of renal, neurologic, and hematologic emergencies

INTRODUCTION

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder with systemic manifestations and multiorgan involvement. Although primarily diagnosed, and managed in the outpatient setting, it can occasionally present with life-threatening complications that require rapid assessment and urgent aggressive therapy. Areas covered: In our review, we explore three organ systems that are often affected in SLE, but have the potential to present as medical emergencies; these are the kidney, the central nervous system, and the hematologic system. We take a case-based approach to each clinical scenario, with information given sequentially in order to reflect "real-life" situations where management decisions need to be made with limited information. We review the acute management, pathophysiology, diagnostic approach, and treatment along with a review of the literature, for lupus nephritis presenting as rapidly progressive glomerulonephritis, acute lupus transverse myelitis, and refractory antiphospholipid syndrome. Expert commentary: At the conclusion of each section, we provide an expert commentary regarding each issue, relating to diagnosis, early management, and current evidence behind treatment recommendations.

Zika virus infection in the returning traveller: what every neurologist should know

Zika virus has been associated with a wide range of neurological complications. Neurologists in areas without current active transmission of the virus may be confronted with Zika-associated neurological disease, as a large number of returning travellers with Zika virus infection have been reported and the virus continues to spread to previously unaffected regions. This review provides an overview of Zika virus-associated neurological disease and aims to support neurologists who may encounter patients returning from endemic areas.

Chiari I malformation in children with transverse myelitis

PURPOSE

Transverse myelitis (TM) is an acute inflammatory spinal cord injury. Asymptomatic Chiari I malformation (CMI) management is highly controversial, particularly when associated with a spinal syrinx. Here, we assess the occurrence of CMI in the pediatric TM population and management outcomes.

METHODS

We performed a retrospective cohort study based on 61 consecutively identified pediatric TM cases over an -8-year period. We reviewed demographic characteristics, radiographic findings, presenting symptoms, and long-term outcomes.

RESULTS

Eight CMI cases were identified within the TM cohort; all presented with TM by 16 months of age and affecting the cervical spinal cord. In three cases, CMI developed 15 months to 6 years after the onset of TM. One in 10 children with TM had CMI.

CONCLUSION

These findings demonstrate a high prevalence of CMI in patients with TM. Large prospective clinical studies are needed to further investigate the natural history and recovery strategies of CMI involved with neuroinflammatory disorders.

Guillain-Barré syndrome, transverse myelitis and infectious diseases

Guillain-Barré syndrome (GBS) and transverse myelitis (TM) both represent immunologically mediated polyneuropathies of major clinical importance. Both are thought to have a genetic predisposition, but as of yet no specific genetic risk loci have been clearly defined. Both are considered autoimmune, but again the etiologies remain enigmatic. Both may be induced via molecular mimicry, particularly from infectious agents and vaccines, but clearly host factor and co-founding host responses will modulate disease susceptibility and natural history. GBS is an acute inflammatory immune-mediated polyradiculoneuropathy characterized by tingling, progressive weakness, autonomic dysfunction, and pain. Immune injury specifically takes place at the myelin sheath and related Schwann-cell components in acute inflammatory demyelinating polyneuropathy, whereas in acute motor axonal neuropathy membranes on the nerve axon (the axolemma) are the primary target for immune-related injury. Outbreaks of GBS have been reported, most frequently related to Campylobacter jejuni infection, however, other agents such as Zika Virus have been strongly associated. Patients with GBS related to infections frequently produce antibodies against human peripheral nerve gangliosides. In contrast, TM is an inflammatory disorder characterized by acute or subacute motor, sensory, and autonomic spinal cord dysfunction. There is interruption of ascending and descending neuroanatomical pathways on the transverse plane of the spinal cord similar to GBS. It has been suggested to be triggered by infectious agents and molecular mimicry. In this review, we will focus on the putative role of infectious agents as triggering factors of GBS and TM.

Autoimmune Neurological Conditions Associated With Zika Virus Infection

Zika virus (ZIKV) is an emerging flavivirus rapidly spreading throughout the tropical Americas. Aedes mosquitoes is the principal way of transmission of the virus to humans. ZIKV can be spread by transplacental, perinatal, and body fluids. ZIKV infection is often asymptomatic and those with symptoms present minor illness after 3 to 12 days of incubation, characterized by a mild and self-limiting disease with low-grade fever, conjunctivitis, widespread pruritic maculopapular rash, arthralgia and myalgia. ZIKV has been linked to a number of central and peripheral nervous system injuries such as Guillain-Barré syndrome (GBS), transverse myelitis (TM), meningoencephalitis, ophthalmological manifestations, and other neurological complications. Nevertheless, mechanisms of host-pathogen neuro-immune interactions remain incompletely elucidated. This review provides a critical discussion about the possible mechanisms underlying the development of autoimmune neurological conditions associated with Zika virus infection.

A multicentre randomiSed controlled TRial of IntraVEnous immunoglobulin compared with standard therapy for the treatment of transverse myelitis in adults and children (STRIVE)

BACKGROUND

Transverse myelitis (TM) is an immune-mediated disorder of the spinal cord that affects adults and children and that causes motor, sensory and autonomic dysfunction. There is a prolonged recovery phase, which may continue for many years. Neuromyelitis optica (NMO) is an uncommon relapsing inflammatory central nervous system condition in which TM can be the first presenting symptom. As TM and NMO affect many patients in the prime of their working life, the disorder can impose a significant demand on health resources. There are currently no robust controlled trials in children or adults to inform the optimal treatment of TM. However, treatment with intravenous immunoglobulin (IVIG) is being effectively used in the management of a range of neurological conditions. Although other interventions such as plasma exchange (PLEX) in addition to intravenous (IV) methylprednisolone therapy can be beneficial in TM, PLEX is costly and technically challenging to deliver in the acute setting. IVIG is more readily accessible and less costly.

OBJECTIVE

To evaluate whether additional and early treatment with IVIG is of extra benefit in TM compared with standard therapy with IV steroids.

DESIGN

A multicentre, single-blind, parallel-group randomised controlled trial of IVIG compared with standard therapy for the treatment of TM in adults and children.

PARTICIPANTS

Patients aged ≥ 1 year diagnosed with either acute first-onset TM or first presentation of NMO. Target recruitment was 170 participants (85 participants per arm).

INTERVENTIONS

Participants were randomised 1 : 1 to treatment with IV methylprednisolone only or treatment with IV methylprednisolone plus 2 g/kg of IVIG in divided doses within 5 days of the first commencement of steroid therapy.

MAIN OUTCOME MEASURES

Primary outcome measure - American Spinal Injury Association (ASIA) Impairment Scale at 6 months post randomisation, with a good outcome defined by a two-grade change. Secondary and tertiary outcome measures - ASIA motor and sensory scales, Expanded Disability Status Scale, health outcome, quality of life, Client Service Receipt Inventory and International Spinal Cord Injury Pain, Bladder and Bowel Basic Data Sets.

RESULTS

In total, 26 participants were screened and two were randomised into the study. With the limited sample size, treatment effect could not be determined. However, we identified barriers to accrual that included strict inclusion criteria, the short enrolment window, challenges associated with the use of the ASIA Impairment Scale as an outcome measure and estimation of the incidence of TM.

CONCLUSIONS

The study did not reach the end point and the effect of IVIG in TM/NMO could not be determined. Investigators should be aware of the potential challenges associated with carrying out a rare disease trial with a short enrolment window. The study question is one that still necessitates investigation. Preliminary work to ameliorate the effect of the barriers encountered in this study is vital.

TRIAL REGISTRATION

EudraCT 2014-002335-34, ClinicalTrials.gov NCT02398994 and Current Controlled Trials ISRCTN12127581.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 31. See the NIHR Journals Library website for further project information. Funding was also received from Biotest AG, Germany (supply of IVIG) and the Transverse Myelitis Society (excess research cost to facilitate study initiation).

Familial monophasic acute transverse myelitis due to the pathogenic variant in VPS37A

Objective

To identify genetic differences among siblings with a family history of idiopathic transverse myelitis (ITM).

Methods

We compared whole-exome sequencing (WES) on germline samples from the 2 affected sisters with ITM with 3 of their healthy siblings.

Results

The 2 sisters with ITM both had acute onset of sensory loss in the legs, weakness, and bowel/bladder dysfunction. The first developed ITM at age 15 years with a clinical nadir of complete paralysis, which slowly recovered over a few years. MRI demonstrated a persistent T2 lesion in the lower thoracic cord. The second developed ITM at age 50 years with a nadir of sensory loss from T6 down and paraparesis in the legs, associated with an MRI lesion at T6. She also made a partial recovery with treatment. Both sisters are homozygous for a missense variant in VPS37A (c.700C>A, p.Leu234Ile) identified by WES. We performed targeted sequencing of VPS37A in an additional 86 samples from patients with ITM and 175 with other diseases to investigate the p.Leu234Ile variant. We identified another patient with ITM homozygous for the same rare variant. No patients with multiple sclerosis, neuromyelitis optica, other neurologic conditions, or any healthy controls in public databases were homozygous for this variant.

Conclusions

A rare missense variant in VPS37A may predispose to development of ITM. Further studies are necessary to determine the frequency of this variant in the patient population and the mechanism through which it contributes to the risk of disease.

Randomized, Placebo-controlled Crossover Study of Dalfampridine Extended-release in Transverse Myelitis

Background

Dalfampridine has the potential to be effective in patients with transverse myelitis (TM) as this rare disorder shares some clinical and pathogenic similarities with multiple sclerosis.

Methods

This is a randomized, double-blind, placebo-controlled crossover study of dalfampridine extended-release (D-ER, Ampyra®). Sixteen adult study participants with monophasic TM confirmed by MRI were enrolled if their baseline timed 25-foot walking speed was between 5 and 60 seconds. Participants were randomized to receive 10 mg twice-daily doses of either D-ER or placebo control for eight weeks, then crossed over to the second arm of placebo or dalfampridine for eight weeks. The primary outcome measure was the timed 25-foot walk.

Results

Of 16 enrolled participants, three withdrew and 13 completed the trial. Among the 13 completers, nine individuals showed an average timed walk that was faster in the D-ER arm compared to the placebo arm, but only four participants met the stricter statistical threshold to be classified as a responder. Analyses of secondary clinical outcome measures including strength, balance assessments, spasticity, and Expanded Disability Status Scale (EDSS) score showed trends toward improvement with D-ER.

Conclusions

D-ER may be beneficial in TM to improve walking speed and other neurological functions.

Encephalitis and myelitis in tropical countries: Report from the Task Force on Tropical Diseases by the World Federation of Societies of Intensive and Critical Care Medicine

Tropical diseases are those that occur primarily or solely in the tropics, and as such include infectious diseases that are particularly prevalent in hot, humid conditions. The incidence of encephalitis in tropical countries is reported to be as high as 6.34/100,000/year. The term encephalitis implies inflammation of the brain and includes the presence of encephalopathy with two and more of the following features: fever, seizures and/or focal neurological findings; a cerebrospinal fluid pleocytosis; electroencephalographic findings or abnormal neuroimaging suggestive of encephalitis. Transverse myelitis (TM) is an inflammation of the spinal cord which has a wide variety of clinical presentations depending on the degree (severity of myelin and neuronal injury) and site of spinal cord involvement. In the present article we discuss the various forms of tropical, viral encephalitides and myelitis and the diagnosis and management.

Thyroid hormone level is associated with the frequency and severity of acute transverse myelitis

Acute transverse myelitis (ATM) is a progressive and autoimmune disease with inflammatory cell infiltrates into the spinal cord, and thyroid hormone (TH) level is associated with the oxidative and antioxidant status. Variations in oxidative stress and antioxidant levels are related to the pathogenesis of autoimmune and inflammatory diseases. Our study aimed to investigate the possible correlation between ATM and TH levels of thyroid-stimulating hormone (TSH), free thyroxine (FT4), free triiodothyronine (FT3), and FT4/FT3. We measured serum concentrations of TSH, FT4, and FT3 in 205 individuals, including 42 ATM patients, 49 multiple sclerosis patients, and 114 healthy controls. Our findings show that ATM patients had lower levels of TSH and FT3 and higher levels of FT4 and FT4/FT3 compared with healthy controls, whether male or female. Moreover, levels of TSH and FT3 in patients with ATM were inversely correlated with disease severity measured by the Expanded Disability Status Scale. Variations in TH level may represent the oxidative status and are surrogate biomarkers of the incidence and severity of ATM.

The diagnosis and clinical management of the neuropsychiatric manifestations of lupus

Neuropsychiatric (NP) involvement in Systemic Lupus Erythematosus (SLE), can be a severe and troubling manifestation of the disease that heavily impacts patient's health, quality of life and disease outcome. It is one of the most complex expressions of SLE which can affect central, peripheral and autonomous nervous system. Complex interrelated pathogenetic mechanisms, including genetic factors, vasculopathy, vascular occlusion, neuroendocrine-immune imbalance, tissue and neuronal damage mediated by autoantibodies, inflammatory mediators, blood brain barrier dysfunction and direct neuronal cell death can be all involved. About NPSLE a number of issues are still matter of debate: from classification and burden of NPSLE to attribution and diagnosis. The role of neuroimaging and new methods of investigation still remain pivotal and rapidly evolving as well as is the increasing knowledge in the pathogenesis. Overall, two main pathogenetic pathways have been recognized yielding different clinical phenotypes: a predominant ischemic-vascular one involving large and small blood vessels, mediated by aPL, immune complexes and leuko-agglutination which it is manifested with more frequent focal NP clinical pictures and a predominantly inflammatory-neurotoxic one mediated by complement activation, increased permeability of the BBB, intrathecal migration of autoantibodies, local production of immune complexes and pro-inflammatory cytokines and other inflammatory mediators usually appearing as diffuse NP manifestations. In the attempt to depict a journey throughout NPSLE from diagnosis to a reasoned therapeutic approach, classification, epidemiology, attribution, risk factors, diagnostic challenges, neuroimaging techniques and pathogenesis will be considered in this narrative review based on the most relevant and recent published data.

Longitudinal myelitis in patient with systemic lupus erythematosus, homozygous prothrombin G20210A and heterozygous MTHFR 677T

Longitudinal myelitis is an uncommon complication of systemic lupus erythematosus (SLE). We describe an unusual case of longitudinal myelitis and ischemic stroke in the presence of homozygous prothrombin G20210A, heterozygous MTHFR 677T mutations and the absence of antiphospholipid antibodies in a young woman with SLE. Lupus (2007) 16, 517—520.

Clinical insights for early detection of acute transverse myelitis in the emergency department

Objective

Acute transverse myelitis (ATM) is characterized by motor weakness, sensory changes, and autonomic dysfunction. However, diagnosis of ATM is based on early-stage clinical features only (and clarification of the cause of disease), which are difficult for emergency department (ED) physicians owing to low incidence rates. We performed retrospective analysis of ATM in order to provide clinical insights for early detection.

Methods

Medical records of patients, who were finally diagnosed with ATM from January 2005 to February 2013, were investigated. Data, including demographics, clinical findings, and radiographic findings, were reviewed.

Results

Forty-six patients were included in the present study, with a mean age of 43.4 years. Sensory changes were identified in 45 patients (97.8%), motor weakness in 33 patients (71.7%), and autonomic dysfunction in 35 patients (76.1%). Thirty patients (65.2%) showed high signal intensity in T2-weighted magnetic resonance imaging (MRI), with lesions most frequently found in the thoracic level of the spinal cord (56.7%). There were discrepancies between sensory changes and levels of MRI lesions. Thirty-five patients (76.1%) were diagnosed with idiopathic ATM. Initial diagnostic impressions in the ED were herniated intervertebral disc (38.7%), stroke (19.4%), Guillain-Barré syndrome (12.9%), cauda equina syndrome (9.7%), ATM (9.7%), and others (9.7%).

Conclusion

When a patient presents with motor weakness, sensory changes, or autonomic dysfunction, ATM should be initially considered as a differential diagnosis, unless the ED physician’s impression after initial evaluation is clear.

Concomitant acute transverse myelitis and sensory motor axonal polyneuropathy in two children: two case reports

Acute transverse myelitis (ATM) is an upper motor neuron disease of the spinal cord, and concomitant association of peripheral polyneuropathy, particularly the axonal type, is rarely reported in children. Our cases presented with ATM complicated with axonal type polyneuropathy. Axonal type polyneuropathy may be caused by acute motor-sensory axonal neuropathy (AMSAN) or critical illness polyneuropathy and myopathy (CIPNM). These cases emphasize the need for nerve and muscle biopsies to make the differential diagnosis between AMSAN and CIPNM in patients with ATM complicated with axonal polyneuropathy.

Transverse myelitis extended to disseminated encephalitis in systemic lupus erythematosus: Histological evidence for vasculitis

A 42-year-old woman was admitted due to systemic lupus erythematosus complicated with glomerulonephritis and pulmonary hypertension. During the treatment for these complications, she presented motor paresis and sensory loss caused by transverse myelitis. In spite of methyl prednisolone pulse therapy, she further developed acute confusional state due to disseminated encephalitis and fell into respiratory arrest. On laboratory examination, elevation of anti-NR2 antibodies in serum as well as in cerebrospinal fluid was noted. Although she recovered from the disseminated encephalitis after extensive treatment with high doses of corticosteroid and intravenous cyclophosphamide, she suddenly died of pulmonary hypertension. Autopsy findings confirmed the presence of liquefaction necrosis in the entire circumference of the whole spinal cord along with intimal hyperplasia and obliteration of the small arteries, accompanied by mononuclear cell infiltration and disruption of internal elastic lamina. It is therefore most likely that our patient developed longitudinal transverse myelitis through spinal cord vasculitis, which extended to brainstem and brain parenchyma, leading to the development of disseminated encephalitis.

Myelitis in systemic lupus erythematosus frequently manifests as longitudinal and sometimes occurs at low disease activity

Background

Transverse myelitis (TM) is a relatively infrequent but severe complication in systemic lupus erythematosus (SLE). Owing to its rarity and unfavorable outcome, we investigated its general features on MRI and incidence in the context of lupus activity, to facilitate early recognition and treatment.

Methods

We report a case of a young man with clinically inactive lupus nephritis but who presented with a sudden attack of myelitis. We performed systematic literature search in Medline to study the clinical features of SLE-related TM.

Results

From 1960 to April 2013, a total of 72 articles containing 194 cases of lupus myelitis were found. Among acquired articles, 93 patients fulfilled the inclusion criteria. The majority of the cases (88.8%) were female. Longitudinal myelitis was the predominant imaging finding on MRI (71.4%, 45/63). Nearly two-thirds (61/94) of lupus myelitis occurred in association with active lupus, and one-third (33/94) occurred in low disease activity.

Conclusions

Upon literature review, we found myelitis in SLE more frequently manifested as longitudinal on MRI. Although lupus myelitis often presented at an active phase of SLE, one-third of events happened in the presence of low disease activity. Early initiation of effective immunosuppressive therapy facilitated recovery.

Transverse myelitis and acute HIV infection: a case report

BACKGROUND

Most HIV infected patients will develop some sort of neurologic involvement of the disease throughout their lives, usually in advanced stages. Neurologic symptoms may occur in acute HIV infection but myelopathy in this setting is rare. Up until this date, only two cases of transverse myelitis as a manifestation of acute HIV infection have been reported in the literature. Therapeutic approach in these patients is not well defined.

CASE PRESENTATION

A 35 year-old male Caucasian recently returned from the tropics presented to our hospital with urinary retention and acute paraparesis. After extensive diagnostic workup he was diagnosed with acute HIV infection presenting as transverse myelitis. Full neurologic recovery was observed without the use of anti-retroviral therapy.

CONCLUSION

Acute spinal cord disorders are challenging, as they present a wide array of differential diagnosis and may lead to devastating sequelae. Timely and rigorous diagnostic workup is of the utmost importance when managing these cases. Clinicians should be aware of the protean manifestations of acute HIV infection, including central nervous system involvement, and have a low threshold for HIV screening.

Prognostic indicators of acute transverse myelitis in 39 children

BACKGROUND

The Transverse Myelitis Consortium Working Group has proposed new diagnostic criteria for acute transverse myelitis. The purpose of the present study is to evaluate the relations between clinical variables and functional prognosis using new criteria.

METHODS

We reviewed 39 Chinese cases meeting the new criteria, recorded clinical epidemiological data, and followed activities of daily living measuring scale (Modified Barthel Index).

RESULTS

Thirty-nine children met new criteria for definite acute transverse myelitis in the past 14 years between 1995 and 2008. Mean follow-up time was 102.7 months. Conversion to multiple sclerosis occurred in two patients (5.1%). Those children with a short time to maximal deficits, long time of peak neurological impairment and initial time of treatment, increased protein levels of the cerebrospinal fluid, and secondary infection were more likely to have residual neurological deficits, resulting in lower qualities of life (P = 0.005, P = 0.003, P = 0.011, P = 0.0012, P = 0.000, respectively).

CONCLUSIONS

A short time to maximal deficits, long time of peak neurological impairment and initial time of treatment, increased protein levels of cerebrospinal fluid, and secondary infection played important roles in predicting poor prognosis.