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1296 Transverse Myelitis

flaccid, with diminished deep tendon reflexes CT myelogram may also be obtained.
BASIC INFORMATION mimicking a peripheral neuropathy. Chest CT scan if sarcoidosis is suspected.
One third to one half of patients present with
DEFINITION localizing back pain. LABORATORY TESTS
Demyelination in a transverse region of the There is progression to nadir of clinical deficits Lumbar puncture looking for CSF pleocytosis,
spinal cord due to an inflammatory process between 4 hr and 21 days after symptom onset. oligoclonal bands for MS, aquaporin 4 anti-
that leads to sensory and motor changes below Urinary incontinence or retention, GI distur- bodies, or infection such as varicella zoster
the lesion and autonomic dysfunction. The term bances (incontinence or constipation), and virus PCR and enterovirus PCR.
transverse myelitis of late refers to any cause sexual dysfunction are common. ANA, hepatitis B serology, Lyme disease titer,
of inflammatory myelopathy, irrespective of Acute flaccid myelitis is a subtype of myelitis VDRL, SSA, SSB, anticardiolipin antibody,
severity or degree of structural or functional in which patients present with acute limb copper, vitamin B12, treponemal antibody.
interruption of pathways through a transverse weakness and have primarily involvement of Serum NMO-IgG and myelin oligodendrocyte
spinal cord section. Patients usually experience gray matter on spinal cord imaging. glycoprotein (MOG) antibodies to evaluate for
bandlike symptoms, which is classically an area neuromyelitis optica.
ETIOLOGY
of altered sensation or pain in a horizontal (i.e.,
Can be idiopathic demyelination (15%-30%)
transverse) band usually at the dermatomal
or demyelination secondary to neurologic
TREATMENT
level corresponding to the lesion within the cord.
Transverse myelitis that extends across three and systemic conditions. Corticosteroids (IV methylprednisone 1 g/day
or more segments of the cord is referred to Secondary causes include postinfection, post- for 3-7 days) are the first-line treatment for
as longitudinally extensive transverse myelitis. vaccination, acute demyelinating encephalo- transverse myelitis; IVIG, plasma exchange,
The pathologic hallmark of transverse myelitis myelitis (where transverse myelitis tends to cyclophosphamide, and rituximab are other
is the presence of focal collections of lympho- be monophasic), and others such as multiple acute therapies used, although there is no
cytes and monocytes with varying degrees of sclerosis, neuromyelitis optica (NMO), mixed evidence-based medicine for use of corticoste-
demyelination, axonal injury, and astroglial and connective tissue disorders, sarcoidosis, and roids, plasma exchange, or IVIG.
microglial activation within the spinal cord. paraneoplastic conditions, which can be pro-
gressive or relapsing. NONPHARMACOLOGIC THERAPY
SYNONYMS About 50% of patients have had a recent Physical therapy
Idiopathic transverse myelitis upper respiratory infection. Respiratory and oropharyngeal support
TM Epstein-Barr virus and cytomegalovirus are
most common viral infections. ACUTE GENERAL Rx
ICD-10CM CODES Hepatitis B, varicella, enterovirus, rhinovirus, High-dose IV corticosteroid (e.g., methylpred-
G37.3Acute transverse myelitis in mycoplasma, syphilis, measles, Lyme disease nisolone 1000 mg/day for 3-5 days).
demyelinating disease of central are less common. Rescue therapy with plasma exchange may
nervous system be helpful in patients who do not respond to
G04.89Other myelitis DIAGNOSIS corticosteroids.
Combination therapy with plasmapheresis
EPIDEMIOLOGY & DIFFERENTIAL DIAGNOSIS and corticosteroids or other immunosuppres-
DEMOGRAPHICS sive agents (e.g., cyclophosphamide) may
MS
INCIDENCE: Annual incidence ranges from 1.3 also be effective.
Neuromyelitis optica (NMO)
to 8 cases per million. The incidence increases Naproxen, ibuprofen for pain.
Spinal cord tumors
to 24.6 cases per million annually if causes of Herniated or slipped discs
acquired demyelination such as multiple sclero- CHRONIC Rx
Spinal stenosis Baclofen, tizanidine, or some other muscle
sis (MS) are included. Abscess
PREVALENCE: Unknown relaxant for muscle spasms
Vascular malformation Gabapentin for pain
PREDOMINANT SEX: None, but female prepon-
derance seen in cases associated with multiple WORKUP Low-molecular-weight heparin for DVT pro-
sclerosis. phylaxis in patients with immobility
Transverse myelitis (TM) should be suspected in
GENETICS: No genetic predisposition has been patients with a history of rapid (hours to days) DISPOSITION
shown. onset of motor weakness and sensory abnor-
PEAK INCIDENCE: Can occur at any age. Bimodal One third of patients with transverse myelitis
malities with bladder or bowel dysfunction that will have complete recovery, one third will
peak in the incidence between 10 to 19 yr and 30 to is referable to the spinal cord. The dysfunction is
39 yr. 20% of cases occur in children with a bimodal have fair recovery, and one third have perma-
bilateral (not necessarily symmetric) and there nent disability and do not recover. Recurrence
peak of incidence between 0 to 2 yr and 5 to 17 yr. is a clearly defined sensory (dermatomal) level.
RISK FACTORS: Infection, vaccination or relapse is possible.
It is important to distinguish idiopathic TM from Patients who need further care, including those
TM due to MS or neuromyelitis optica because with urinary retention, may need home nursing
PHYSICAL FINDINGS & CLINICAL
idiopathic TM does not relapse and does not assistance. Some patients may benefit from
PRESENTATION
require long-term immunomodulatory therapy. rehabilitation, either inpatient or outpatient.
The clinical signs are caused by an interrup-
tion in ascending and descending neuroana- IMAGING STUDIES REFERRAL
tomic pathways in the transverse plane of the Gadolinium-enhanced magnetic resonance
spinal cord, and a resulting sensory level is Consider physical therapy.
imaging (MRI) of brain and MRI of the entire Consider occupational therapy.
characteristic of transverse myelitis. spine (Fig. E1). This will show demyelinating
Rapid onset of symmetric or asymmet- Consider rehabilitation services.
lesion on T2 with contrast enhancement. In Consider psychiatric consultation (high inci-
ric paraparesis or paraplegia of the lower MS there is a short segment lesion (less than
extremities over a few days, ascending par- dence of long-term mood and anxiety disorders).
three vertebral segments) that is dorsally
esthesia, sensory level at the trunk, back pain, located. Longitudinally extensive transverse
sphincter dysfunction, and positive Babinski, myelitis that spans more than three or more SUGGESTED READING
which can be bilateral. The arms may also segments of the cord is typical of NMO. Available at www.expertconsult.com
be involved but less than the legs in most Computed tomography (CT) of the spine
cases. In the acute phase the weakness is should be obtained if MRI is unavailable. AUTHOR: PADMAJA SUDHAKAR, M.B.B.S.
Descargado para Anonymous User (n/a) en Universidad Nacional Autonoma de Mexico de ClinicalKey.es por Elsevier en septiembre 19, 2017.
Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
Transverse Myelitis 1296.e1

SUGGESTED READING
Frohman EM, Wingerchuk DM: Transverse myelitis, N Engl J Med 363:564, 2010.

FIG. E1 Patient with clinical picture of trans-


verse myelitis.Sagittal T2-weighted MRI of the
distal cord shows central T2 hyperintensity within the
conus medullaris (arrows) in this case of ADEM. An
acute spinal cord infarct also could have this imag-
ing appearance. (From Fuhrman BP etal: Pediatric
critical care, ed 4, Philadelphia, 2011, Saunders.)

Descargado para Anonymous User (n/a) en Universidad Nacional Autonoma de Mexico de ClinicalKey.es por Elsevier en septiembre 19, 2017.
Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.