Human T-lymphotropic virus type I or II (HTLV-I/II) associated with recurrent longitudinally extensive transverse myelitis (LETM): two case reports

Concurrent Longitudinal Extensive Transverse Myelitis and Leptomeningitis in West Nile Virus: A Report of a Rare Case

Here we report a rare case with concurrent longitudinal extensive transverse myelitis (LETM) and leptomeningitis due to West Nile virus infection. A 47-year-old man initially presented with a six-day progressive, intermittent low-grade fever, headache, diplopia, malaise, myalgia, lower back pain, and difficulty walking that developed into progressive asymmetric paralysis. Initial lab work was notable for mild lactic acidosis and hyperCKemia. Brain MRI with contrast demonstrated small foci of leptomeningeal enhancement in the cerebellum, pons, medulla, and right CN VI at the cisternal segment. MRI of the spine was remarkable for edema in the spinal cord extending from T10 to L1 with diffuse enlargement of the cord contour at T11 to L1 and subtle enhancement of nerve roots within the thecal sac and cauda equina regions. The patient responded partially to five-day intravenous immunoglobulin therapy (total dose, 2 g/kg). Electromyography four months after the onset of symptoms also showed chronic reinnervation with active denervating features in thoracolumbar myotomes. Clinically, this case highlights the ill-defined and non-specific nature of the presentation of West Nile neuroinvasive disease. It can pose a diagnostic challenge for clinicians and, if unrecognized, is associated with significant morbidity and mortality in older and compromised individuals.

Longitudinally extensive transverse myelitis in a patient infected with West Nile virus

Until now, longitudinally extensive transverse myelitis (LETM) was reported in association with various viral infections. We describe the case in which a diagnosis of LETM was established as a clinical manifestation of West Nile virus (WNV) infection. We report a 39-year old man with WNV infection and LETM. In neurological examination, there was a left periscapular hypotrophy, moderate weakness of left arm, decreased left brachioradialis reflex, tandem instability and gait ataxia. Cervical spine MRI showed enhancing intramedullary lesion extending from C3-C7 level. According to the neurological, EMG and MRI findings, a diagnosis of LETM, with affection of anterior horn cells of the cervical spinal cord, induced by WNV infection was established. The patient was treated with antibiotics, acyclovir and high dose-steroids, methylprednisolone (MP) 1 g/daily in intravenous infusion, for 5 consecutive days, followed by tapering doses of prednisone during the next four months. Six weeks after onset of symptoms, previously described lesion on cervical spine MRI resolved, and the patient gradually clinically improved.

Parasitic and rare spinal infections

The imaging features of spinal parasitic diseases and other rare infections are herein discussed. These diseases are distributed worldwide, with increased prevalence in areas with poor sanitary conditions and in developing countries. In nonendemic areas, sporadic cases may occur, consequent to increased international travel and immunocompromising conditions. Infectious diseases are usually treatable, and early detection is often crucial. A thorough comprehension of the imaging patterns associated with the clinical features, epidemiology, and laboratory results allows the radiologist to narrow down the options for differential diagnosis and facilitates the timely implementation of appropriate therapies.

Aquaporin-4 immuneglobulin g testing in 36 consecutive jamaican patients with inflammatory central nervous system demyelinating disease

Epidemiological studies of neuromyelitis optica (NMO) in Jamaica are lacking. Here we reviewed the clinical records of 700 patients undergoing neurological evaluation at the Kingston Public Hospital, the largest tertiary institution in Jamaica over a 4 month period. We investigated the diagnostic utility of Aquaporin-4 ImmuneglobulinG (AQP4-IgG) testing in 36 consecutive patients with a diagnosis of an inflammatory demyelinating disorder (IDD) of the central nervous system (CNS). Patients were classified into 3 categories: i) NMO, n=10; ii) multiple sclerosis (MS), n=14 and iii) unclassified IDD (n=12). All sera were tested for AQP-IgG status by cell binding assay (Euroimmun). No MS cases were positive. Ninety per cent of NMO cases were positive. Four of 12 patients with unclassified IDD tested positive for AQP4-IgG. AQP4-IgG seropositivity was associated with a lower socioeconomic status, higher EDSS (P=0.04) and lower pulmonary function than the seronegative cases (P=0.007). Aquaporin-4 autoimmunity may account for a significant proportion of Jamaican CNS IDDs.

Longitudinal extensive transverse myelitis--it's not all neuromyelitis optica

Longitudinal extensive transverse myelitis (LETM) is defined as a spinal cord lesion that extends over three or more vertebrae, as seen on MRI of the spine. The clinical presentation of a patient with LETM is often dramatic and can consist of paraparesis or tetraparesis, sensory disturbances, and gait, bladder, bowel and/or sexual dysfunction. LETM is a characteristic feature of neuromyelitis optica, but such spinal lesions can also occur in various other autoimmune and inflammatory diseases that involve the CNS--such as multiple sclerosis, sarcoidosis or Sjögren syndrome--or in infectious diseases with CNS involvement. Patients with a neoplastic disorder or traumatic spinal cord injury can also present with longitudinal spinal lesions. In this Review, the signs and symptoms that suggest various etiologies and differential diagnoses of LETM are described, and illustrated by educational case studies. The best therapeutic options for patients with each diagnosis are also discussed.