Case presentation on transverse myelitis

an excellent summary of the case with its brief scientific background

1. Case p resentation on Transverse Myelitis (TM) By Dr. Mestet Yibeltal ( Neurosurgery resident) Moderator: Dr. Teklil ( Consultant Neurologist) 7/30/2020 1

2. OUTLINE Patient clinical profile Investigations Diagnosis Treatment Patient response Scientific background of TM Reference 7/30/2020 2

3. Identification Id:86035 Age: 20 Sex: M Occupation: policeman Residence: Arsi Ethnicity: Oromo Chief complaint: bilateral lower extremity of 1 month duration 7/30/2020 3

4. HPI A 20 years old right handed policeman Healthy one month back Started to have a sudden onset of weakness of his LT LE while he was walking. The weakness was more distally that then progressed and incapacitated him to walk with in one day. The day after his LE weakness, he started to have a right LE weakness and followed the same progress like his LE. 7/30/2020 4

5. CONT’D In association to his LE weaknesses, he started to have urinary retention, fecal incontinence and mid back pain of similar onset. He lost any form of sensation to his LE after 2 days. He had symptoms of UTI 1 week after initial symptoms. 7/30/2020 5

6. CONT’D For the above compliants , he visited health center on the 2 nd day of onset of symptoms where he was catheterized , given IM medication, and on 4 th day, he was referred to Adama General Hospital, where he was appointed for observation with no medication. He then self referred the same day to police hospital, where he was imaged with thoracic MRI, admitted and stayed 2 weeks & referred to TASH with no improvement. 7/30/2020 6

7. CONT’D No previous hx of chronic medical illness No trauma No recent hx of bowel habit change & URTI complaints No fever No symptom complex of tuberculosis & previous TB No hx of visual complaint No hx recent vaccination No hx of photosensitivity, body rash No river water contact No radiation hx Sero status unknown 7/30/2020 7

8. Physical examination (12/7/20) GA: ASL Vital sign: BP: 110/70, To: 36.5 PR:96 RR:24, SPO2: 98% with atmospheric air HEENT: pink conjunctiva & NIS LGS: no LAP RS: resonant, good air entry with intact diaphragmatic strength bilaterally CVS: s1 & s2 well heard. No murmur Abdomen: flat, no organomegally & sign of fluid collection PR: lax tone 7/30/2020 8

9. CONT’D GUS: Catheterized, no CVAT, 1400ml/24hrs UOP MSS: no tenderness , deformity Integumentary: no rash, pallor, no edema 7/30/2020 9

10. CONT’D NS : GCS:15/15 Pupil: mid size & reactive to light bilaterally Visual field & acuity: intact Eye moves in all direction Intact cornel reflex Face is symmetric Intact gag & swallowing reflex Central tongue with active movement 7/30/2020 10

11. Motor exam Power Tone LE RT + LT RT +LT Dorsiflexors 0/5 Atonic Plantar flexors 0/5 Knee flexors 0/5 Knee extensors 0/5 Hip adductors 0/5 Hip abductors 0/5 Hip flexors 0/5 Hip extensors 0/5 UE 5/5 2/5 7/30/2020 11

12. CONT’D Sensory exam Sensory level: at T6/7 Sweat level: at T6/7 Position sensation: absent Reflex: Areflexic LE bilaterally & normal reflex at UE Plantar reflex: equivocal bilaterally Abdominal & bulbocavernous reflex: a bsent Meningeal signs: - ve 7/30/2020 12

13. Localization Is it neurologic? 7/30/2020 13

14. Investigations summary IX Date 6/11/12 8/11/12 CBC WBC 9.9k 9.3k neut lym Hct 48.2% 46.3% PLT 295k 295k ESR 25mm/ hr RFT normal LFT electrolyte PIHCT Non reactive ANA, RF - ve 7/30/2020 14

15. MRI 7/30/2020 15

16. DDX of TM 7/30/2020 16

17. DX PARAPLEGIA 20 LONGITUDINAL EXTENSIVE TRANSVERSE MYELITIS + SPINAL SHOCK+UTI 7/30/2020 17

18. RX Dexamethasone 8mg QID ACYCLOVIR 800MG PO Q4HR ESOEPROLE 40MG IV QD UFH 7500IU SC BID GENTMYCIN 160MG IV QD, now on 4 th day on meropene m BEDSIDE PHYSIOTHERPY 7/30/2020 18

19. Progress (18 & 19/07/20) Subjectively : No back pain Can control pass urine and control feaces but has frequency& dysuria Catheter removed Still has urgency, dysuria & frequency No back pain Started sensation in his LE Started new onset of constiption , rxed & improved Can't move LE 7/30/2020 19

20. CONT’D Objectively: Motor exam: same except hip & flexors:1/5 areflexic , hypotonic Sensory exam: intact for crude touch, pain& To. Position sensation: absent Plantar reflex: equivocal Bulbocavernous reflex : absent Anal tone: absent Asst : improving 7/30/2020 20

21. Transverse myelitis   is a segmental spinal cord injury caused by acute inflammation of d/t etiology. Epidemiology 1-4 new cases per million people per year. peaks ages 10-19 years and 30-39 years  .   no sex or familial predisposition. 7/30/2020 21

22. Causes Post infectious Post vaccination multiple sclerosis Neuromyelitis optica Acute disseminated encephalomyelitis Myelopathies Associated with Other Connective tissue inflammatory disorders ( SLE,Sjogren’s syndrome, scleroderma, Behcet’s disease, and sarcoidosis ) idiopathic 7/30/2020 22

23. Pathophysiology Three hypotheses: Cell mediated autoimmune response Autoimmune vasculitis Direct viral invasion of spinal cord. 7/30/2020 23

24. Clinical presentation Variable but typically evolves over hrs or days. Combination of 1. Sensory 2. Motor 3. bladder symptoms Usually bilateral Complete vs Incomplete Band like sensation (pressure, pain, numbness ) over the trunk. Why p a in? 7/30/2020 24

25. Course of ATM proceeds through three stages: 1. initial motor loss precedes sphincter dysfunction in most patients, sensory loss usually over 2 to 3 days 2. plateau phase: mean duration is 1 week 3. recovery phase. 7/30/2020 25

26. Diagnosis Laboratory Aids • MRI and CSF analysis: two most important tests in ATM . • Enhancing spinal cord lesion or pleocytosis or increased IgG index is required for the diagnosis. • If both tests are negative, repeat tests in 2 to 7 days is recommended. 7/30/2020 26

27. Rx First line : high dose iv steroids (methylprednisolone) Second line : If poor response to high-dose steroids after 5 to 7days use . Plasma Exchange (PLEX) Intravenous immunoglobulin Plasma exchanges Rituximab Cyclophosphamide . Care of the paraplegic patient 7/30/2020 27

28. Natural History and Prognosis The progression of symptoms in ATM Often slows within 2 to 3 weeks of onset With a corresponding improvement in CSF and MRI abnormalities 1/3 pts have a complete recovery 1/3 pts have some residual deficit 1/3 pts have no improvement from nadir Majority monophasic disease without recurrence. 7/30/2020 28

29. Prognosticators Unfavorable outcomes 1. Rapid progression to maximal neurologic deficit (<24 hrs ) 2. Severe motor weakness 3. Spinal shock 4. Back pain as the initial complaint, and 5. Sensory disturbances at the cervical level Better outcome 1. Older age 2. Increased deep tendon reflexes 3. Presence of the babinski sign 7/30/2020 29

30. Sample references Localiz a tion in clinical neurology, 5 ed. Harrison’s neurology in clinical medicine 2 nd ed. Pandey S, Garg RK, Malhotra HS, Jain A, Malhotra KP, Kumar N, Verma R, Sharma PK. Etiologic spectrum and prognosis in noncompressive acute transverse myelopathies: An experience of 80 patients at a tertiary care facility. Neurol India 2018;66:65-70 Tan W, Lim CT. Dengue-related Longitudinally Extensive Transverse Myelitis. Neurol India 2019;67:1116-7 7/30/2020 30

31. 7/30/2020 31 THANK YOU