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.
Extrinsic Compression (usually causes myelopathy)
- fracture, degenerative disease, disc
- B12 deficiency (AKA subacute combined degeneration)
- Copper deficiency
- anterior spinal artery infarct
- dural AV fistula
- demyelinating disease
- acute disseminated encephalomyelitis
- infectious or post-infectious
- WNV, HSV, HIV, HTLV-1, Zika
- lyme, mycoplasma, syphillis
- pyogenic bacteria rarely cause intrinsic spine dysfunction (usually compressive)
- other rheumatologic conditions
- ankylosing spondylitis
- Mixed connective tissue disease
- leptomeningeal lymphoma or solid tumor
- idiopathic – 30% of transverse myelitis is ultimately thought to be idiopathic
- 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
- 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
Frohman EM. Wingerchuk DM. Transverse myelitis. NEJM 363;6. 564-572