An acute transverse myelitis attack after total body irradiation: a rare case

Radiation induced delayed transverse myelitis and neurological deficit at tertiary care center

Background

Transverse myelitis is a rare spinal cord inflammation with absence of a compression. It varies in presentation based on the pathology location, and mainly causes a combined deficit of motor, sensory, and autonomic functions. History, physical examination, and other diagnostic tests including blood tests and an MRI are important tools to establish a diagnosis.

A thorough neurological evaluation helps localize the affected region of the spinal cord. The management includes rehabilitation as any other spinal cord injury. If very severe, a multidisciplinary rehabilitation program will be required.

Presentation

We explain a case in which a 43-year-old male patient, known to have chronic myelogenous leukemia (CML), on Imatinib (a tyrosine kinase inhibitor), started complaining of back pain at the level of the 10th rib. Different tests were made including a PET-CT (Positron Emission Tomography-Computed Tomography) which showed hypermetabolic bony lytic lesion in the left mandible at the level of temporomandibular joint, destruction of the 10th rib, and no evidence of spinal cord compression. Other etiologies were excluded, making transverse myelitis due to radiation for the patient's CML on top of the differential diagnosis.

Conclusion

A thorough physical examination and diagnostic tests are important tools to exclude other etiologies of complex neurological deficit in a patient with CML.

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Transverse myelitis can be a possible complication post-radiation for CML treatment.

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Careful history taking, meticulous physical examination, and investigations are necessary.

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Avoid delaying intervention once a diagnosis has been made to avoid neurological impairment.

Current Status and Perspectives of Irradiation-Based Conditioning Regimens for Patients with Acute Leukemia Undergoing Hematopoietic Stem Cell Transplantation

Acute myeloid leukemia and acute lymphoblastic leukemia are the most common indications for allogeneic hematopoietic stem cell transplantation. Total body irradiation (TBI) is an important part of conditioning regimens. TBI-based regimens offer advantages in sanctuary sites but are associated with significant risks of early and late side effects, including pulmonary toxicity, growth retardation, and second malignancy. TBI is also associated with technical problems, such as dose heterogeneity. With evolving techniques in radiation oncology, it is possible to focus the dose to the entire skeleton while sparing the rest of the body. This technique is called total marrow irradiation (TMI). TMI is able to deliver the same or higher doses to bone marrow while reducing toxicity. With the success of TMI, we are moving toward ultra-personalized conditioning. We review the clinical role of the irradiation-based regimens currently in clinical use, emphasizing on their strengths and limitations. Novel technologies with targeted irradiation accompanied by the modern imaging techniques and increased knowledge of the disease process can help us achieve our goal of maximum response with minimum toxicity.