Myelopathy and myelitis

Andy Romeo co-hosted my last morning report ever! We talked about a middle aged man with myelitis, meningitis, and radiculopathy that remains a diagnostic mystery. We developed an approach to myelitis and myelopathy.

Transverse myelitis definition

  • Bilateral (doesn’t have to be symmetric) motor deficit + sensory deficit + bowel/bladder sx that localizes to the cord
  • defined sensory level
  • progression->nadir of symptoms in 4 hours->21 days (so not hyper acute and not chronic)
  • If a patient only has sensory or motor deficits rather than all three, they have partial myelitis.

Myelitis/myelopathy ddx

Extrinsic Compression (usually causes myelopathy)

  • Tumor
  • abscess
  • bone/disc
    • fracture, degenerative disease, disc

Intrinsic problem

myelopathy

  • metabolic
    • B12 deficiency (AKA subacute combined degeneration)
    • Copper deficiency
  • vascular
    • anterior spinal artery infarct
    • dural AV fistula
  • post-radiation

myelitis

  • demyelinating disease
    • MS
    • NMO
    • acute disseminated encephalomyelitis
  • infectious or post-infectious
    • viral
      • WNV, HSV, HIV, HTLV-1, Zika
    • bacterial
      • lyme, mycoplasma, syphillis
      • pyogenic bacteria rarely cause intrinsic spine dysfunction (usually compressive)
  • other rheumatologic conditions
    • ankylosing spondylitis
    • neurosarcoidosis
    • APLS
    • Behcets
    • Mixed connective tissue disease
    • RA
    • scleroderma
    • sjogrens
    • SLE
  • malignant
    • paraneoplastic
    • leptomeningeal lymphoma or solid tumor
  • idiopathic – 30% of transverse myelitis is ultimately thought to be idiopathic
Workup
  • Imaging is key! Start with a sagittal survey of the whole spine, then zoom in on the area of suspected deficit + anything that looks abnormal on the sagittal survey.
  • Most need an LP and a big serologic workup. Here’s starting recommendations from NEJM
Screen Shot 2017-05-31 at 10.00.18 AM.png
Bonus pearls!
  • this patient was treated empirically for cryptococcal meningitis but there was still concern for cancer – either leptomeningeal carcinomatosis or lymphoma. It turns out that the flucytosine in his crypto regimen can occasionally, partially treat a malignancy, which could explain the improvement in his symptoms.
  • A very high CSF protein level will cause xanthochromia that is unrelated to lysis of RBCs
Citations:
Frohman EM. Wingerchuk DM. Transverse myelitis. NEJM 363;6.  564-572
Evernote: 
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