Neuroscience · Year 2 · from Neuroscience
Case 3: Transverse Myelitis
Patient Presentation
Demographics: 28-year-old female
Chief Complaint: Progressive leg weakness and numbness for 3 days
History of Present Illness: A 28-year-old previously healthy woman presents with ascending numbness that began in her feet 3 days ago and has progressed to her mid-abdomen. She noticed leg weakness yesterday and today cannot walk. She also reports a "band-like" tightness around her mid-torso and difficulty emptying her bladder. She had a mild upper respiratory infection 2 weeks ago. She denies back pain, trauma, or recent travel. She has no history of neurological symptoms.
Physical Examination:
- Vital signs: Normal
- General: Anxious young woman in no acute distress
- Neurological:
- Mental status: Normal
- Cranial nerves: Intact
- Motor: Upper extremities 5/5 throughout; bilateral hip flexors 3/5, knee extension 3/5, ankle dorsiflexion 2/5
- Tone: Increased in lower extremities
- Sensory: Dense sensory level at T8; all modalities reduced below this level
- Reflexes: 3+ at knees and ankles; bilateral upgoing Babinski responses
- Coordination: Normal in upper extremities
- Gait: Unable to walk
- Bladder: Post-void residual 400 mL
Workup:
- MRI spine (complete): T2 hyperintense signal within the spinal cord from T6-T9; cord swelling; partial gadolinium enhancement
- MRI brain: Normal (no demyelinating lesions)
- Lumbar puncture: Elevated protein (85 mg/dL); 45 WBC (lymphocyte predominant); normal glucose; oligoclonal bands negative
- CSF viral studies: Negative
- NMO-IgG (AQP4 antibody): Negative
- MOG antibody: Negative
- Infectious workup: Negative
Diagnosis: Idiopathic acute transverse myelitis
Treatment:
- IV methylprednisolone 1 g daily for 5 days
- Plasma exchange initiated after incomplete response to steroids
- Foley catheter for urinary retention
- DVT prophylaxis
- Physical therapy
- Monitoring for development of MS or NMOSD (30-40% of transverse myelitis cases evolve to MS)
- Gradual improvement over 6 weeks; ambulatory with a cane at 3 months
Clinical Pearl: Transverse myelitis is an inflammatory myelopathy causing motor, sensory, and autonomic dysfunction below the level of the lesion. The "transverse" descriptor indicates that the entire cord width is affected at the involved levels. Key features include bilateral symptoms, a sensory level, and sphincter dysfunction. MRI shows cord signal abnormality, often with swelling and enhancement. Approximately 30-40% of cases represent the first manifestation of multiple sclerosis (MS), particularly when brain lesions are present. Longitudinally extensive lesions (3+ segments) raise concern for neuromyelitis optica spectrum disorder (NMOSD), which has different treatment implications.
Clinical Image
Image Description: Cross-sectional diagram of the spinal cord showing the organization of major ascending and descending tracts, including the lateral corticospinal tract, posterior columns (fasciculus gracilis and cuneatus), and anterolateral spinothalamic tract, demonstrating the somatotopic organization relevant to central cord syndrome.
Attribution: Image from Wikimedia Commons (https://commons.wikimedia.org/), Creative Commons Attribution-ShareAlike license.