Unusual viral causes of transverse myelitis: hepatitis A virus and cytomegalovirus

Cytomegalovirus infection in non-immunocompromised critically ill patients: A management perspective

Critically ill patients are a vulnerable group at high risk of developing secondary infections. High disease severity, prolonged intensive care unit (ICU) stay, sepsis, and multiple drugs with immunosuppressive activity make these patients prone to immuneparesis and increase the risk of various opportunistic infections, including cytomegalovirus (CMV). CMV seroconversion has been reported in up to 33% of ICU patients, but its impact on patient outcomes remains a matter of debate. Even though there are guidelines regarding the management of CMV infection in immunosuppressive patients with human immunodeficiency virus/ acquired immuno deficiency syndrome, the need for treatment and therapeutic approaches in immunocompetent critically ill patients is still ambiguous. Even the diagnosis of CMV infection may be challenging in such patients due to non-specific symptoms and multiorgan involvement. Hence, a better understanding of the symptomatology, diagnostics, and treatment options may aid intensive care physicians in ensuring accurate diagnoses and instituting therapeutic interventions.

[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.

[Extra hepatic manifestations of hepatitis A]

Viral hepatitis A is characterized by a wide range of clinical pictures ranging from a completely unapparent infection to a fulminant, potentially fatal hepatitis or the classical icteric form. Hepatitis A can develop in an unusual way and extrahepatic manifestations (neurological, renal, haematological, cholecystitis, acute pancreatitis, vasculitis, etc.) can occasionally complicate the course of the disease. Although hepatitis A infection was identified in the early 1970s, there are few or no studies assessing the actual frequency of these complications. They have been studied mainly through clinical case reports. Currently, since the disease has become more common in adults, these complications are being increasingly observed. We present an update on extrahepatic complications during hepatitis A, which should be known by both specialist doctors (infectiologists internists, hepatologists and others) and general practitioners.

Disseminated inflammation of the central nervous system associated with acute hepatitis E: a case report

BACKGROUND

Hepatitis E infection affects over 20 million people worldwide. Reports of neurological manifestations are largely limited to the peripheral nervous system. We report a middle-aged genotype 3c male patient with acute hepatitis E virus (HEV) infection and severe neurological deficits with evidence of multiple disseminated inflammatory lesions of the central nervous system.

CASE PRESENTATION

A 42-year-old male patient presented to our emergency department with musculoskeletal weakness, bladder and bowel retention, blurred vision and ascending hypoesthesia up to the level of T8. Serology showed elevated liver enzymes and positive IgM-titers of hepatitis E. Analysis of cerebrospinal fluid (CSF) showed mild pleocytosis and normal levels of glucose, lactate and protein. HEV-RNA-copies were detected in the CSF and stool. Within 3 days after admission the patient became paraplegic, had complete visual loss and absent pupillary reflexes. MRI showed inflammatory demyelination of the optic nerve sheaths, multiple subcortical brain regions and the spinal cord. Electrophysiology revealed axonal damage of the peroneal nerve on both sides with absent F-waves. Treatment was performed with methylprednisolone, two cycles of plasma exchange (PLEX), one cycle of intravenous immunoglobulins (IVIG) and ribavirin which was used off-label. Liver enzymes normalized after 1 week and serology was negative for HEV-RNA after 3 weeks. Follow-up MRI showed progressive demyelination and new leptomeningeal enhancement at the thoracic spine and cauda equina 4 weeks after admission. Four months later, after rehabilitation was completed, repeated MRI showed gliotic transformation of the spinal cord without signs of an active inflammation. Treatment with rituximab was initiated. The patient remained paraplegic and hypoesthesia had ascended up to T5. Nevertheless, he regained full vision.

CONCLUSIONS

Our case indicates a possible association of acute HEV infection with widespread disseminated central nervous system inflammation. Up to now, no specific drugs have been approved for the treatment of acute HEV infection. We treated our patient off-label with ribavirin and escalated immunomodulatory therapy considering clinical progression and the possibility of an autoimmune response targeting nerve cell structures. While response to treatment was rather limited in our case, detection of HEV in patients with acute neurological deficits might help optimize individual treatment strategies.

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.

Transverse myelitis caused by hepatitis E: previously undescribed in adults

We report the case of a 62-year-old Caucasian woman who was admitted with urinary retention and lower limb paraesthesia following a week's prodromal illness of headache and malaise. Liver function tests showed a picture of acute hepatocellular dysfunction. She developed reduced lower limb power, brisk reflexes, extensor plantars, a sensory level at T8 and reduced anal sphincter tone, establishing a clinical diagnosis of transverse myelitis. A spinal MRI showed no evidence of cauda equina or spinal cord compression. Cerebrospinal fluid (CSF) analysis showed raised protein and raised white cell count. Hepatitis E IgM and IgG were positive and hepatitis E virus was found in her CSF. She was treated with methylprednisolone and is slowly recovering with physiotherapy.

Acute necrotizing encephalopathy (ANE1): rare autosomal-dominant disorder presenting as acute transverse myelitis

The term "acute transverse myelitis (ATM)" comprises various non-traumatic disorders that eventually can be associated with a focal myelopathy. Patients characteristically present with an acutely occurring paraparesis/plegia and require a comprehensive and timely diagnostic work up for the initiation of an appropriate treatment. We present a case of a 36-year-old female patient with a rare genetic disorder (ANE1: Acute Necrotizing Encephalopathy due to a RANBP2 mutation) who presented with an acute quadriplegia. Following an acute pulmonal infection, she rapidly (< 24 h) developed a severe quadriplegia (total motor score 38) with some facial sensory symptoms (perioral hypoesthesia). Magnetic resonance imaging (MRI) revealed a combination of longitudinal extensive transverse myelitis and symmetrical thalamic lesions. A work-up for infectious and systemic diseases was negative; specifically, no findings related to multiple sclerosis, neuromyelitis optica or vascular disorders. After empirical high dose steroid treatment and rehabilitation therapy, the patient gained almost normal gait and upper limb function. She was found to carry an autosomal-dominant missense mutation in the RANBP2 gene predisposing for ANE. Gene segregation was confirmed in other family members that had been affected by other episodes of acute steroid-responsive encephalopathies. We propose that a redefined diagnostic workup of ATM might include ANE1, as the frequency of this rare disorder might be underestimated.

Infectious myelopathies

Every genus of microorganism, as well as prions, has been associated with disease of the spinal cord. The spectrum of pathogens resulting in myelopathy varies with the population. Myelopathy is uniquely associated with certain retroviruses, particularly HIV type 1 and human T-cell lymphotropic virus type I, but the myelopathies that occur with these viruses are chiefly limited to "at risk" populations. In the immunocompromised population, a diverse array of pathogens may cause spinal cord disease, especially viruses from the Herpesviridae family, most notably cytomegalovirus and varicella-zoster virus. The prototypical myelopathy resulting from bacterial infection is tabes dorsalis, but this disorder is vanishingly rare in the modern era. In developing countries, Mycobacterium tuberculosis and schistosomiasis remain significant causes of myelopathy.

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.

Immune-mediated myelitis associated with hepatitis virus infections

Virus-induced spinal cord damage results from a cytolytic effect on anterior horn cells or from predominantly cellular immune-mediated damage of long white matter tracts. Infection with the hepatitis virus group, most notably hepatitis C virus, has infrequently been associated with the occurrence of myelitis. The pathogenesis of hepatitis virus-associated myelitis has not been clarified: virus-induced autoimmunity (humoral or cell-mediated, possibly vasculitic) seems the most likely disease mechanism. Limited available information offers no evidence of direct hepatitis virus infection of the spinal cord. Virus neuropenetration may occur after virus-infected mononuclear cells penetrate the blood-brain barrier, but a true neurolytic effect has not been demonstrated. Attacks of acute myelitis usually respond favorably to immunomodulatory therapy. Antiviral therapy plays no confirmed role in the treatment of acute bouts of myelitis, but may limit the relapsing course of HCV-associated myelitis.

Neuromuscular complications of hepatitis A virus infection and vaccines

The hepatitis A virus (HAV) infects millions of people worldwide every year. Case histories report on various acute neuropathy syndromes in the context of acute HAV infection, but any causal link has not been established. Epidemiological data also cast doubt on the importance of HAV as a trigger for Guillain-Barré syndrome. The virtual absence of a chronic HAV-infected state likely explains the rare occurrence of extrahepatic immune-mediated diseases, including an absence of chronic autoimmune neuromuscular disorders. Several vaccines against HAV provide effective protection against natural infection. Isolated case histories report on an unconvincing association between HAV vaccination and neuropathy. Medical and epidemiological data show insufficient evidence to support a causal relationship between HAV vaccines and neuropathy syndromes. Aluminum hydroxide, a HAV vaccine adjuvant, is considered a trigger of the macrophagic myofasciitis syndrome. This review concludes that it seems unnecessary to routinely consider HAV infection or vaccination as triggers of neuromuscular diseases.

Recurrent polymorphonuclear pleocytosis with increased red blood cells caused by varicella zoster virus infection of the central nervous system: Case report and review of the literature

We describe an immunocompetent 45-year-old woman who had four episodes of neurological disease (meningoencephalitis, multifocal vasculopathy, myelitis and inflammatory brain stem disease) produced by varicella zoster virus (VZV) over an 11-month period, all in the absence of rash. The cerebrospinal fluid (CSF) contained anti-VZV IgG antibody, but not VZV DNA throughout her illness, reaffirming the superiority of detection of anti-VZV IgG in CSF compared to VZV DNA in diagnosing VZV infection of the nervous system. Moreover, 3 of 7 CSF samples examined during the 11 months showed a VZV-induced pleocytosis consisting predominantly of polymorphonuclear cells (PMNs), and 4 of 7 samples also contained increased numbers of red blood cells (RBCs). Because increased PMNs and RBCs in CSF can also occur in patients with central and peripheral nervous system disease produced by cytomegalovirus (CMV), the differential diagnosis of chronic nervous system infection with increased PMNs and RBCs in CSF should include analyses for both VZV and CMV.

The epidemiology of transverse myelitis

Transverse myelitis is a neurological disorder causing acute spinal cord injury as a result of acute inflammation, often associated with para infectious processes and autoimmune disease. The purpose of this article is to review the literature on the geoepidemiology of transverse myelitis and assess its environmental associations. Articles from 1981 to 2009 were reviewed in Pub Med along with potential causes such as autoimmune disease (focusing on systemic lupus erythematosus (SLE), antiphospholipid antibody syndrome (APS), and Sjogren's), infection, vaccination, and intoxication.

Hepatitis A: disease burden and current childhood vaccination strategies in the United States

Hepatitis A can be a serious disease and represents a substantial health and economic burden. In recent years, a decline in the number of cases of hepatitis A has been observed, which has been attributed in part to the implementation of vaccination policies in states with high disease incidence. In May 2006, the Advisory Committee on Immunization Practices published updated recommendations to include routine hepatitis A vaccination for all children beginning at 12 to 23 months of age. In this review, information on hepatitis A disease burden is presented with a discussion on the new recommendations and implementation of hepatitis A vaccination.

[A new case of acute transverse myelitis following hepatitis A virus infection]

Transverse myelitis is a rare manifestation of hepatitis A virus infection. We report the case of an eleven-year-old girl who presented a progressive flabby paraplegia with sphincter incontinence, superficial hypoesthesia, without deep involvement. Medullar MRI was suggestive of myelitis. Despite the absence of jaundice and hepatic cytolysis, the serology yielded a high rate of anti-hepatitis A immunoglobulin M. Neurological disorders disappeared within 15 days, after treating with a high dose of corticosteroids and physical rehabilitation. 24 months later she was asymptomatic. Screening for hepatitis A virus infection in patients with acute transverse myelitis should be indicated specially in endemic countries were vaccinal prophylaxis is not common practice.

Myélopathies aiguës transverses : myélopathie inflammatoire ou ischémique ?

The rapid development of paraparesis or tetraparesis combined with a bilateral sensory deficit that has a clearly defined rostral border and bladder dysfunction are the principal features of acute transverse myelopathy. Acute partial transverse myelopathy is far much more frequent: its symptoms are asymmetric, sometimes unilateral, and sensory deficit may predominate. An urgent MRI is required to exclude acute spinal cord compression. Diagnosis of ischemic acute transverse myelopathy includes the following elements: sudden onset, neurologic symptoms compatible with infarction in the anterior spinal artery area (by far the most frequent location for spinal cord infarction), and presence of a specific cause of spinal cord ischemia. In all other cases where it is difficult to distinguish spinal cord infarction from myelitis, analysis of the cerebrospinal fluid is essential. Most cases of inflammatory acute transverse myelopathy can be linked to a defined cause. Multiple sclerosis is a major cause of partial acute transverse myelopathy. MRI lesions are usually small, located in the lateral or posterior part of the spinal cord. Diagnostic elements include multiple lesions of multifocal demyelination on the cerebral MRI, oligoclonal bands in the cerebrospinal fluid, and the absence of clinical or laboratory abnormalities that suggest systemic disease. Neuromyelitis optica, also known as Devic's disease, has often been considered a variant form of multiple sclerosis. Recent immunologic studies confirm the hypothesis that it is a distinct entity. Infectious transverse acute myelitis is often of viral origin. It may result from direct viral stress but more frequently follows immunologically-mediated indirect stress. This acute parainfectious myelitis, like postvaccinal myelitis, may be considered as a spinal single-focus form of acute disseminated encephalomyelitis (ADEM). It is important to distinguish the latter from an initial episode of multiple sclerosis, because their prognosis and treatment differ.

Acute transverse myelitis due to Coxsackie virus

The case of a young adult male, who after a short upper respiratory illness presented with fever and alarming progressive neurological deficits, is reported. The diagnostic puzzle and the difficulty in establishing a diagnosis are reported. Acute transverse myelitis is a rare clinical manifestation of Coxsackie virus infection, and very few cases of transverse myelitis caused by serotype B have been reported in the English literature. This is a case report of an unusual acute transverse myelitis caused by Coxsackie B2 infection.

[Infectious myelopathies: clinical, serological, and prognostic patterns]

INTRODUCTION

Serological confirmation of an infectious acute myelitis injury is difficult to confirm as it is sometimes due to a post-infectious etiology.

OBJECTIVES

The aim of this study was to define the clinical, biological and prognostic patterns of infectious myelitis.

PATIENTS AND METHODS

This retrospective study included 153 subjects hospitalized in the department of neurology between 1993 and 2002 for treatment of a noncompressive acute myelopathy. Biological confirmation of recent infection was obtained in 12 patients (8 p. 100).

RESULTS

An infectious syndrome, beginning prior to the neurological symptoms, was found in 67 percent of patients. The clinical symptoms were severe with loss of sensoromotor and sphincter functions and ascending spinal cord dysfunction (acute transverse myelopathy). Spinal cord MRI showed extended centromedullar high intensity signals with rapid and complete regression. CSF analysis cell count was above 30/mm3 with hyperproteinorachia, in 75 percent and 58 percent of patients respectively. CSF electrophoresis did not detect oligoclonal bands. Clinical outcome was good in all patients except one, however sphincter disorders recovered slowly.

DISCUSSION

Our study illustrates a stereotypical clinical, biological and prognostic pattern for infectious acute myelitis. These findings contribute significantly to therapeutic decision making and establishing prognosis at the initial phase of acute myelopathy.

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.

Cytomegalovirus-associated transverse myelitis in a non-immunocompromised patient

DESIGN

Single case report.

OBJECTIVE

To report a rare case of cytomegalovirus (CMV)-associated transverse myelitis (TM) in the immunocompetent host.

SETTINGS

Collaboration between a Neurology and Radiology University Department in Greece and a Molecular Virology Department in Cyprus.

PATIENT

A 16-year-old male student developed an acute febrile illness followed shortly by TM, that resulted in paraplegia over 24 h. Rapid clinical improvement was followed by complete recovery in 2 months. Extensive laboratory work-up excluded other possible causes of TM and showed no evidence of an immunocompromised state. Antiviral serological data, identification of the viral genome by polymerase chain reaction and serial spinal cord magnetic resonance imaging findings, supported the diagnosis of CMV-associated TM in a non-immunocompromised patient.

CONCLUSIONS

Our case further indicates that CMV infection should be included in the differential diagnosis of TM of uncertain etiology, in the immunocompetent patient. Clinical, immunological and neuroimaging findings indicate that post-infectious immune mediated inflammation, seems the most probable pathogenetic mechanism in this case.

Sensory neuropathy in the prodromal phase of hepatitis A and review of the literature

We report an unrecognized clinical presentation of hepatitis A with unilateral peripheral acute sensory loss in the prodromal phase of the illness. Although rare, focal neurological signs are known to occur in hepatitis A before, during and after the icteric phase; a pure peripheral sensory neuropathy is distinctly uncommon. Possible lesions could include radiculopathy of the lower thoraco-lumbo-sacral dorsal nerve roots or a partial transverse myelitis of Brown-Séquad like distribution. The signs and symptoms lasted only a few days and the patient had an uneventful recovery.

Multiple sclerosis, acute disseminated encephalomyelitis, and related conditions

Multiple sclerosis (MS) and acute disseminated encephalomyelitis (ADEM) are conditions whose closely related pathology suggests shared pathophysiological elements, but whose clinical courses are usually, but not always quite dissimilar. The former is largely a disease of adulthood, the latter of childhood. Optic neuritis, demyelinative transverse myelitis, and Devic's syndrome are neurological syndromes that may occur as manifestations of either MS or ADEM. Patients with Miller-Fisher syndrome and encephalomyelradiculoneuropathy usually have features suggesting ADEM in combination with acute demyelinative polyneuropathy. These various conditions and other forms of ADEM share an indistinct border with encephalitides, granulomatous, and vasculitic conditions. MS, ADEM, and the pertinent syndromic subtypes, their differential diagnosis, treatment, and prognosis are considered in this review. Acute cerebellar ataxia is a syndrome that is likely to be pathophysiologically distinct from ADEM, although its occurrence as a postinfectious illness suggests a distant kinship. It is also reviewed.

[Cytomegalovirus myeloradiculitis in pregnancy]

INTRODUCTION

Cytomegalovirus neurological complications are frequent in immunocompromised patients specially in HIV positive patient. In immunocompetent patient these complications are infrequent.

EXEGESIS

We describe a case of cytomegalovirus myeloradiculitis during pregnancy in a 25-year-old woman, HIV negative. The evolution was favorable with foscarnet therapy.

CONCLUSION

A spinal complication during cytomegalovirus infection in immunocompetent patient should lead to a therapy with a specific antiviral to reduce neurologic involvement.

Cytomegalovirus-associated transverse myelitis in a non-immunocompromised patient

Cytomegalovirus (CMV)-associated transverse myelitis is rare in immunocompetent patients. The case of a 54-year-old man is reported here who developed acute transverse myelitis with cerebrospinal fluid (CSF) alterations, suggesting a central nervous system infection. CMV-IgM positivity in serum and CMV isolated from blood, positive CMV PCR and positivity for pp65 antigen in blood, without viral antigens in the CSF and a positive response to therapy with ganciclovir (followed by progressive improvement) supported the diagnosis.

Acute transverse myelitis in childhood: nine cases and review of the literature

Acute transverse myelitis (ATM) is a rare disease in childhood and adolescence. It is characterized by paraplegia with or without sensory symptoms and bladder dysfunction, and typically manifests itself over a period of hours to 1 week. This is a report of nine patients who were treated between 1993 and 1996. To exclude treatable conditions, spinal and cranial MRI with and without contrast medium, electrophysiologic tests, and CSF examinations are performed as soon as possible after onset. At present post- or parainfectious inflammation is thought to be the most frequent cause of ATM. Some causes of ATM can be proved only by follow-up examination. The most important differential diagnoses are multiple sclerosis and Guillain-Barré syndrome with its variants. After exclusion of spinal cord compression, and if specific antibiotic treatment is not possible, a 3-day high-dose i.v. steroid pulse therapy is the most promising treatment. Prognosis is variable and residual symptoms are common. A controlled multicenter study is suggested to assess epidemiology, etiology, and prognosis of ATM.

Cell types involved in replication and distribution of human cytomegalovirus

As the number of patients suffering from severe HCMV infections has steadily increased, there is a growing need to understand the molecular mechanisms by which the virus causes disease. The factors that control infection at one time and the events leading to virus multiplication at another time are only beginning to be understood. The interaction of HCMV with different host cells is one key for elucidating these processes. Through modern techniques, much has been learned about the biology of HCMV infections in culture systems. In addition to endothelial cells, epithelial cells, and smooth muscle cells, fibroblasts are one cell population preferentially infected in solid tissues in vivo. From these sites of multiplication, the virus may be carried by peripheral monocytes and circulating endothelial cells to reach distant sites of the body. This would explain the multiorgan involvement in acute HCMV infection and the modes of viral transmission. From what has been learned mainly from human fibroblast culture systems, future studies will focus on how HCMV regulates the expression of its putative 200 genes in different host cells at different stages of cell differentiation and activation to result in viral latency and pathogenesis.

Cytomegalovirus-associated transverse myelitis in a non-immunocompromised patient

Cytomegalovirus-associated transverse myelitis (TM) is rare in immunocompetent patients. We report here the case of a 24-year-old woman who developed acute transverse myelitis with cerebrospinal fluid (CSF) findings, suggesting a central nervous system (CNS) infection, and a positive CMV serology.

Acute transverse myelitis and brainstem encephalitis associated with hepatitis A infection

A 4-year-old boy became paraplegic during the course of hepatitis A infection. There were significant magnetic resonance imaging changes in the cervical spinal cord and brainstem. The patient's cervical myelopathy resolved entirely after 10 weeks.

Acute postasthmatic amyotrophy (Hopkins' syndrome)

Acute postasthmatic amyotrophy is a rare condition, previously reported in only 26 cases. It is characterized by a sudden onset of a flaccid paralysis of an arm or a leg with completely preserved sensibility, about 1 week after an asthmatic attack. The cause is probably due to a lesion of the anterior horn of the spinal cord, but evidence indicates a more widespread pathological process. The etiology is unknown, but infectious or immunological mechanisms are likely.

Inflammation and the brain

Inflammation in the brain selectively damages the myelin sheath resulting in a variety of clinical syndromes of which the most common is multiple sclerosis. In these disorders, the areas of inflammation and demyelination can be identified in life by magnetic resonance imaging. Events occurring at the blood-brain barrier depend on T-cell activation, which increases immune surveillance within the central nervous system. T-cells activated against brain antigens persist to establish the conditions needed for inflammatory demyelination and this depends on local release of cytokines, culminating in removal of oligodendrocytes and their myelin lamellae by macrophages or microglia. These interactions involve binding between receptors present on microglia for the Fc portion of antibody and complement components to corresponding ligands on target cells. Taken together, the evidence from clinical and experimental studies provides a rationale for the issue of immunological treatments in patients with multiple sclerosis.

Transverse myelitis following mumps in children

Although acute transverse myelitis is a rare complication of mumps, it is relatively well documented. We describe a child who developed mumps associated acute transverse myelitis and who subsequently recovered completely. To our knowledge, only 13 cases have been reported in children. This case is compared with 13 previously reported patients.

Transverse myelitis associated with mycoplasma pneumoniae: case report

Acute transverse myelitis (ATM) is a disorder of the spinal region of the central nervous system. In the present case, the clinical course showed ATM associated with mycoplasma pneumoniae (MP) and little recovery; the girl was left with a flaccid paraplegia, and thus differed from other cases in the literature which all reported complete or near-complete recovery.

Acute transverse myelopathy in children

Twenty-three children with acute transverse myelopathy (ATM) are reviewed. Antecedent minor trauma or exercise was reported in 10 patients. Despite a positive history in 7 patients no preceding infection was documented. Two patients had a history of less severe ATM followed by recovery prior to a second more severe episode. The most common initial symptom was back pain and the most prominent clinical signs were weakness, sensory level and sphincter disturbances. Myelography and CT myelography at presentation was performed to exclude a compressive lesion. Spinal cord enlargement was demonstrated in 6 of 21 cases. Magnetic resonance imaging (MRI) of the spinal cord, performed in one patient, showed enlargement of the cord. Poor prognostic features were severity of weakness at the time of maximum deficit and a delayed onset of recovery. Maximum motor recovery occurred at a mean of 6 1/2 months but did not occur in one patient until 1 1/2 years. Normal or good outcome was obtained in 64%.