Post-infective transverse myelitis following Streptococcus pneumoniae meningitis with radiological features of acute disseminated encephalomyelitis: a case report

Noncompressive myelopathy in acute community-acquired bacterial meningitis: Report of seven cases and review of literature

BACKGROUND AND PURPOSE

Bacterial meningitis is a severe disease with high rates of complications and unfavorable outcome. Complications involving the spinal cord are rarely reported.

METHODS

Cases of noncompressive myelopathy were identified from a nationwide cohort study of adults with community-acquired bacterial meningitis in the Netherlands. The American Spinal Injury Association Impairment Scale was used to classify the severity of spinal cord dysfunction. Subsequently, we reviewed the literature on noncompressive myelopathy as a complication of bacterial meningitis.

RESULTS

Noncompressive myelopathy was reported in seven of 3047 episodes of community-acquired bacterial meningitis (0.2%). The median age of these patients was 51 years (range = 17-77). Causative pathogens were Streptococcus pneumoniae in three, Streptococcus agalactiae in two, and Neisseria meningitidis and Haemophilus influenzae both in one. Paresis of legs (n = 6) or arms and legs (n = 1) was the presenting symptom, occurring after a median duration of 9 days after admission (range = 2-28). Spinal magnetic resonance imaging showed T2-weighted abnormalities of the spinal cord in six of seven patients. Improvement of spinal cord function during admission was noted in four of seven patients. The literature review yielded 15 additional cases. Among patients from our cohort and the literature, there was no significant association between immunosuppressive therapy and subsequent improvement of spinal cord function (5/8 patients with immunosuppressive therapy [63%] vs. 5/14 without immunosuppressive therapy [36%], p = 0.44).

CONCLUSIONS

Noncompressive myelopathy is an uncommon but severe complication of bacterial meningitis. Improvement after diagnosis is expected, but all patients had persistent neurological deficits.

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.

Myelin oligodendrocyte glycoprotein associated transverse myelitis following brain abscess: Case report and literature review

Transverse myelitis is a subacute immune mediated myelopathy secondary to a range of conditions. Post infectious transverse myelitis can be seen with several infectious etiologies. Myelin oligodendrocyte glycoprotein associated disease (MOGAD) is a relatively recently defined condition frequently manifesting with longitudinally extensive transverse myelitis. Cases of MOGAD have occurred after infection, typically respiratory tract infections. We report an unusual case of MOGAD transverse myelitis following a streptococcal brain abscess which has not been previously reported.

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.

Longitudinally extensive transverse myelitis with anti-NMDA receptor antibodies during a systemic lupus erythematosus flare-up

Transverse myelitis (TM) with systemic lupus erythematosus (SLE) has been linked to the presence of autoantibodies (eg, antiaquaporin 4 (AQP4) and anticardiolipin (aCL)) and SLE-induced secondary vasculitis, but the aetiology remains incompletely understood. A 48-year-old Japanese man with a 6-year history of poorly controlled SLE had stopped glucocorticoid therapy 1 year before admission. 3 days before admission, he developed flaccid paraplegia. Spinal MRI showed a longitudinally hyperintense T2 grey matter lesion from the level of Th4 to the conus medullaris, which was considered longitudinally extensive TM (LETM). We administered steroid pulse therapy (methyl-prednisolone 1000 mg/day) for 3 days and prednisolone 50 mg/day. The patient's flaccid paralysis gradually improved. We concluded that the patient's TM was caused by SLE flare-up, even though we could not completely rule out antiphospholipid syndrome. SLE myelitis is relatively rare and many aetiologies are possible for TM in SLE.