Transverse myelitis secondary to coexistent Lyme disease and babesiosis

OBJECTIVE: To describe transverse myelitis secondary to coexistent Lyme disease and babesiosis. METHOD: Case report. BACKGROUND: A 74-year-old man presented with rapid onset of weakness, numbness, and tingling in his legs, with symptoms ascending to his hands and forearms within days. He recalled an insect bite to his scapular area 2 weeks earlier. FINDINGS: T2-weighted magnetic resonance imaging demonstrated diffuse hyperintensity from T1 through T12. Western blot and enzyme-linked immunosorbent assay identified infection with Borrelia burgdorferi, the spirochete responsible for Lyme disease. Giemsa-stained blood smears identified ring forms later recognized by polymerase chain reaction as Babesia microti, the piroplasm responsible for babesiosis. Initial examination revealed C7 motor and T3 sensory complete tetraplegia, with recovery to T4 paraplegia by 2 months. CONCLUSION: The history, physical examination, imaging, and serologic studies were consistent with transverse myelitis related to Lyme disease and babesiosis. The severity and permanence of this patient's deficits were greater than those reported in the majority of previous cases of transverse myelitis due to Lyme disease alone, suggesting a possible role for coinfection with babesiosis.     

Acute transverse myelitis following scrub typhus: A case report and review of the literature

Context: Scrub typhus is an acute febrile disease caused by Orientia tsutsugamushi. The disease can usually involve the lungs, heart, liver, spleen and brain through hematogenous dissemination. However, very rarely, acute transverse myelitis in the spinal cord develops from scrub typhus. We present a case of acute transverse myelitis following scrub typhus with a review of the literature.

Findings: A 66-year-old male visited a hospital for general myalgia, mild headache, and fever in October. He was noted to have thick, black papule skin on his abdomen, which was highly suggestive of scrub typhus. To confirm the diagnosis, O. tsutsugamushi antibody titers were examined and detected highly in serum by an indirect fluorescence antibody assay. Doxycycline, the standard treatment for scrub typhus, was administered. However, after seven days of treatment, he rapidly developed weakness in the right leg, paresthesia in both lower limbs, and voiding difficulty. Spinal magnetic resonance imaging (MRI) revealed lesions with high signal intensity involving the spinal cord at the thoracolumbar junction. Paraparesis gradually improved following steroid pulse therapy for five days. At one-year follow-up, he could walk without cane.

Conclusions: Orientia tsutsugamushi causes scrub typhus, which can affect not only the brain, but also the spinal cord. Although acute transverse myelitis develops rarely from scrub typhus, this should be considered as differential diagnosis in patients of fever with neurological deficit in endemic areas.     

Acute Transverse Myelitis at the Conus Medullaris Level After Rabies Vaccination in a Patient With Behcet's Disease

Abstract

Case report: A 25-year-old man with BehÇet's disease was admitted because of weakness of the lower limbs and difficulty in urination. He had received a rabies vaccination 2 months previous because he had been bitten by a dog.

Findings: Clinical and laboratory findings supported acute transverse myelitis. A hyperintense lesion and expansion at the level of conus medullaris was detected on spinal magnetic resonance imaging.

Conclusion: Although neurologic involvement is one of the main causes of mortality and morbidity in BehÇet's disease, the factors that aggravate the involvement of the nervous system are still unclear. Vaccination may have been the factor that had activated autoimmune mechanisms in this case. To our knowledge, involvement of the conus medullaris in BehÇet's disease after rabies vaccination has not been reported.     

Orquialgia aguda aislada como síntoma inicial del trastorno de la médula torácica: informe de 2 casos y revisión de la literatura

IntroductionOrchalgia is a common andrological disorder and usually results from pathognomonic change of testes and regional structures. However, responsible cause is still unknown in more than one-fourth of patients.MethodsWe report 2 men who initially suffered an acute, isolated orchalgia and posteriorly complicated with paraparesis. They had previous history of prostate cancer and cervical myelitis. The urological examination was negative in both of them. Finally, prostate cancer metastasis and recurrent myelitis at T2/3 level was identified, respectively. Although their orchalgia progressively subsided, their urological, sexual and neurological dysfunction persisted.ConclusionsIn the literature, the responsible pathology of spinal orchalgia was exclusively found below T10 level, frequently delaying affirmative diagnosis. Therefore, a thorough evaluation of spinal cord above T10 level should be alerted for idiopathic orchalgia with a pre-existing history or risk of spinal cord disorder and a negative urological examination.     

Central Causes of Foot Drop: Rare and Underappreciated Differential Diagnoses

Abstract

Background/Objective: Peripheral causes of foot drop are well recognized. However, causes stemming from the central nervous system represent rare, important, and underappreciated differential etiologies.

Methods: Two cases of foot drop stemming from central causes are described.

Patients: The first patient, a 46-year-old man with a remote history of lumbar spine fracture and L4-L5 instrumentation/fusion, presented with progressive weakness and numbness of the left foot, followed within 3 months by similar symptoms in the right foot. Lumbar spine imaging failed to reveal compressive nerve root pathology. Electromyography, nerve conduction studies, and muscle and nerve biopsy suggested a preganglionic lesion and ruled out a peripheral cause. Upper spine magnetic resonance imaging (MRI) revealed significant spinal stenosis at C4-C7 and T11 -T12. Patient 2 was a 66-year-old man with a known left parasagittal convex meningioma diagnosed 2 years prior presented with a progressive right foot drop over 2 months. Spine imaging was normal, and serial brain MRI confirmed a slowly enlarging parasagittal meningioma.

Results: Following decompressive laminectomies at C4-C7 and T11-T12, patient 1's gait improved, with marked resolution of his right foot drop and significant improvement on the left. Patient 2 underwent craniotomy for microsurgical tumor resection. At the 2-weekfollow-up examination, he was taking daily walks.

Conclusions: Central causes, although rare, need to be considered in the differential diagnosis of foot drop. Central causative lesions usually occur at locations where pyramidal tract connections are condensed and specific and the function is somatotopically organized. These cases confirm that good results can be achieved when correctable central causes of foot drop are recognized.     

Acute transverse myelitis associated with dengue viral infection

Background:

Acute transverse myelitis is a rare manifestation of dengue viral infection. Four cases have been previously reported in the literature.

Objective:

To report a case of a 61-year-old woman who developed acute transverse myelitis 6 days after the onset of a dengue viral infection.

Findings:

Magnetic resonance imaging of spinal cord showed hypersignal intensity on T2W at T9-T10. Laboratories studies revealed a high titer of hemagglutination inhibition of dengue virus. Treatment with intravenous pulse methylprednisolone and physiotherapy yielded a partial recovery, followed by complete resolution at 1 year postinfection.

Conclusion:

Acute transverse myelitis is a rare manifestation of dengue infection that can occur in either the peri-infectious or postinfectious phases.     

Intravesical Capsaicin Therapy: A Review

Abstract

Acute transverse myelitis (ATM) is an acute intramedullary spinal cord disease characterized by an abrupt onset of rapidly progressive weakness of the extremities accompanied by a loss of sensation and sphincter control. Although ATM has an important place in childhood spinal cord disorders, its occurrence remains extremely uncommon in the infant population (0 to 12 months old). This report of a 7 -month-old boy with ATM is followed by a discussion of the case and review of the literature regarding etiology, diagnosis, and prognosis for neurological recovery.     

Dural puncture and iatrogenic pneumocephalus with subsequent transverse myelitis in a parturient

PURPOSE: To report a case of transverse myelitis following inadvertent dural puncture and iatrogenic pneumocephalus and any possible causal relationship is explored. CLINICAL FEATURES: A 32-yr-old primigravida developed a severe headache associated with pneumocephalus following accidental dural puncture when the loss of resistance to air technique was used to locate the epidural space. She was treated with oxygen 100% to promote resorption of the air and the headache resolved. One month later she developed a sensory disturbance in her feet. Neurological examination revealed reduced sensation to cold and pain to ankle level and bilateral suppressed knee and ankle reflexes but was otherwise normal. A spinal cord lesion (epidural abscess/hematoma) was excluded with an emergency T1 and T2 weighted magnetic resonance imaging (MRI) scan of the lumbar spine. Over the next 48 hr the sensory disturbance worsened to involve her legs and waist. Examination revealed a sensory loss to waist level, reduced joint position sense and vibration sense in her lower limbs and absent knee and ankle reflexes bilaterally, but normal power in both her legs. A further full length T2 weighted MRI scan of the spine showed a small area of high signal at the level of T3 compatible with transverse myelitis. This was treated with high dose corticosteroids and her symptoms resolved over the next three months. CONCLUSION: The etiology of transverse myelitis after dural puncture in a parturient could not be identified nor could any causal link be established between the dural puncture, pneumocephalus, and subsequent transverse myelitis.     

Spinal cord astrocytoma mimicking multifocal myelitis

Abstract

Introduction

Differential diagnosis of acute/subacute intrinsic spinal cord lesions can be challenging. In addition, intramedullary neoplasms typically show gadolinium enhancement, mass effect, and cord expansion.

Case report

We report a patient with spinal cord and brain stem lesions resembling multifocal myelitis. Magnetic resonance imaging showed no spinal cord enlargement or gadolinium enhancing. Treatment of myelitis was undertaken without stopping the progression of the disease. Biopsy was made and led to a histological diagnosis of astrocytoma.

Discussion

Astrocytoma must remain as a possible diagnosis of spinal cord lesions, even without typical characteristics of neoplasms. Furthermore, biopsy should always be considered when diagnosis is uncertain.     

Toxocara canis myelitis involving the lumbosacral region: a case report

Context: Toxocara canis is a parasite known to cause visceral larva migrans. The infection rarely affects the central nervous system but there have been several reports of myelitis caused by visceral larva migrans due to Toxocara canis. In previous reported cases, the lesions were located in the thoracic or cervical spinal cord. To the best of our knowledge, this is the first report of a lesion involving the lumbosacral region.

Findings: A 60-year-old man developed weakness and dysesthesia in the lower limbs. The symptoms resolved spontaneously, but recurred after five months. One month later, the patient developed pollakiuria and constipation. He was a dog owner and frequently ate raw chicken meat and beef liver. Sagittal T2-weighted image (T2WI) showed swelling and hyperintensity in the spinal cord from T10 to the lumbosacral region and focal nodular enhancement on the posterior segment of the lumbar spinal cord. Blood cell counts showed slight eosinophilia and elevated serum immunoglobulin E level. Cerebrospinal fluid examination showed slight pleocytosis with eosinophilia. Enzyme-linked immunosorbent assay showed high levels of anti-Toxocara antibodies in the serum and cerebrospinal fluid. In addition, confirmatory test by Western blot was positive. The patient was initially treated with intravenous methylprednisolone with slight improvement in muscle weakness. Albendazole was added with a second course of intravenous methylprednisolone. The muscle weakness in the lower limbs improved considerably, and swelling and hyperintensity on T2WI almost disappeared.

Conclusion: Our results suggest that Toxocara canis myelitis cannot be discounted even if the myelitis involves the lumbosacral region.     

Spinal Hydatid Cyst Mimicking Arachnoid Cyst on Magnetic Resonance Imaging

Abstract

Background: Primary spinal hydatid cysts are uncommon and account for 1% of all cases of hydatid disease. Echinococcus granulosus is most often responsible for the cyst hydatid. Intradural, extramedullary involvement is rare. When the cysts do not demonstrate typical magnetic resonance imaging findings, the differential diagnosis is more complex.

Method: Case report.

Findings: An isolated primary hydatid cyst of the spine in a 35-year-old man that appeared to be an arachnoid cyst on preoperative radiographic examination.

Conclusion: Hydatid cysts that lack the typical radiographic appearance may be mistaken for arachnoid cysts. Misdiagnosis has serious implications for surgical intervention and long-term care.     

Long extensive transverse myelitis associated with aquaporin-4 antibody and breast cancer: Favorable response to cancer treatment

Abstract

Context

Long extensive transverse myelitis (LETM) seldom develops in patients with breast cancer who are aquaporin-4 antibody (Aqp-4 Ab)-positive. Whether this association is coincidental is not well understood.

Findings

A 62-year-old woman presented with treatment-resistant LETM and Aqp-4 Ab. Two months later, a stage 3 invasive ductal carcinoma was detected in her right breast. Following tumor resection and chemotherapy, her neurologic symptoms and magnetic resonance imaging findings significantly improved and serum Aqp-4 Ab disappeared. The breast tumor samples of this patient and neurologically normal patients showed inflammatory infiltrates and Aqp-4 expressing cells.

Conclusion/Clinical Relevance

The temporal association between tumor treatment, amelioration of clinical findings, and seroreversion suggest that coexistence of cancer and LETM is not coincidental. Cancer screening should be considered at least in treatment-resistant LETM cases.     

Seronegative neuromyelitis optica presenting with life-threatening respiratory failure

Context: Dyspnea has rarely been reported as a presenting symptom in patients with neuromyelitis optica (NMO). We report an unusual case of NMO relapse presenting with rapidly progressive respiratory failure and briefly discuss the possible pathophysiological mechanisms of this potential life-threatening complication of NMO.

Findings: The 58-year-old woman with a history of bilateral optic neuritis presented to the emergency department with rapidly worsening dyspnea. Cervical spine magnetic resonance imaging showed extensive abnormal signal with involvement of the medulla oblongata.

Since in our patient chest radiography failed to disclose a diaphragmatic palsy that is commonly observed in patients with phrenic nerve involvement, this acute manifestation of the disease may be attributed to brainstem involvement instead of cervical myelitis.

Conclusion/clinical relevance: Clinicians should be aware of this atypical presentation of NMO, which needs to be promptly recognized and aggressively treated.     

Transverse myelitis in children: long-term urological outcomes

PURPOSE: Urological complications are well documented in patients with traumatic spinal cord injury. We examined the long-term urological outcomes in a large population of children affected by transverse myelitis. MATERIALS AND METHODS: We retrospectively reviewed the medical history, imaging studies and urodynamic findings in 22 children with transverse myelitis. Age at disease onset ranged from 3 months to 18 years (average 8.8 years). RESULTS: At a mean followup of 7.1 years 19 patients (86%) had persistent bladder dysfunction and 17 (77%) had persistent bowel dysfunction. Initial evaluation at least 1 month after disease onset revealed detrusor overactivity in 59% of patients, detrusor external sphincter dyssynergia in 41%, low compliance in 47% and detrusor leak point pressure greater than 40 cm water in 12%. Functional motor recovery and absence of lower extremity spasticity did not reflect normal urodynamic findings. Of the 19 patients with imaging available for review 5 (26%) had upper tract changes. One patient had development of chronic renal insufficiency. Low compliance (p = 0.02) and upper tract changes (p = 0.1) were more frequent in patients who started clean intermittent catheterization more than 2 years after disease onset. CONCLUSIONS: Persistent bowel and bladder dysfunction is common in transverse myelitis. Urodynamic abnormalities may be present despite normal neurological examination and absence of urinary symptoms. All pediatric patients with transverse myelitis require baseline renal ultrasound and urodynamic evaluation to guide treatment. Early institution of clean intermittent catheterization appears to preserve bladder compliance and decrease upper tract disease, and should be instituted at disease onset.     

Primary Spinal Intradural Extramedullary Hydatid Cyst in a Child

Abstract

Background/Objective: Spinal hydatid cyst is a serious form of hydatid disease affecting less than 1% of the total cases of hydatid disease. We present a case of pathologically confirmed primary intradural spinal cyst hydatid in an otherwise healthy patient who showed no other evidence of systemic hydatid cyst disease.

Case Report: An 8-year-old boy presented with back pain, left leg pain, and difficulty in walking. The patient had no other signs of systemic hydatid cyst disease. An intradural extramedullary cystic lesion was identified with magnetic resonance imaging and was shown to be a hydatid cyst by histopathologic examination after the surgical removal.

Conclusion: Although extremely rare, primary intradural extramedullary hydatid cyst pathology might be the cause of leg pain and gait disturbance in children living in endemic areas.     

Recurrent longitudinal extensive transverse myelitis in a neuro-Behçet syndrome treated with infliximab

Abstract

Background

Spinal cord involvement is not common, but can be seen in neuro-Behçet's syndrome (NBS). The major site of involvement is the cervical spinal cord with the myelitis-like inflammatory lesions continuing more than two segments, and extending to the brainstem.

Case

A 30-year-old male patient who has been followed with a diagnosis of Behçet's syndrome admitted to our neurology department clinically and radiologically suggestive of recurrent and extensive longitudinal myelitis. His anti-aquaporine antibody was negative. Because of insufficient effect of azathioprine, cyclophosphamide, and corticosteroids, infliximab was started. His clinical and radiological status is stationary for 3 years under infliximab treatment.

Discussion

Myelitis such as that occurring in our patient may have a similar presentation like neuromyelitis optica (NMO), which should therefore be included in differential diagnosis. Myelitis observed in both NMO and NBS shows spinal cord lesions longer than three or more vertebrae. Anti-aquaporine antibody must be evaluated in all patients presenting with longitudinal myelitis. Anti-tumor necrosis factor agent infliximab might be an alternative treatment in severe form of NBS such as myelitis.

Conclusion

In our case, successful treatment of recurrent and extensive longitudinal transverse myelitis in NBS with infliximab was demonstrated.     

Abstracts from the 43rd Annual Scientific Conference of the American Paraplegia Society—September 2-4, 1997, Las Vegas,Nevada

Abstract

Background: Diagnosing patients with cervical cord compressive myelopathy in a timely manner can be challenging due to varying clinical presentations, the absence of pathognomonic findings, and symptoms that are usually insidious in nature.

Objective: To describe the clinical course of a patient with primary complaint of left medial knee pain that was nonresponsive to surgical and conservative measures; the patient was subsequently diagnosed with cervical cord compressive myelopathy.

Design: Case report.

Subject: A 63-year-old man with a primary complaint of left medial knee pain.

Findings: Physical examination of the left knee was normal except for slight palpable tenderness over the medial joint line. During treatment, he noted loss of balance during activities of daily living. Reassessment revealed bilateral upper extremity hyperreflexia, bilateral Babinski reflex, and positive bilateral Hoffman reflex. Magnetic resonance imaging of the cervical spine demonstrated moderately severe spinal stenosis at the C3-C4, C5-C6, and C6-C7 levels. After C3-C7 laminoplasty for cervical cord compressive myelopathy, he reported substantial improvement of his left medial knee. Three years later, he had no complaint of knee pain.

Conclusion: Appropriate diagnosis and treatment of cervical cord compressive myelopathy may avoid unnecessary diagnostic imaging, medical evaluations, invasive procedures, and potential neurologic complications.     

Myelopathy in West Nile virus encephalitis: Report of a case and review of literature

Context: In West Nile virus (WNV) encephalitis, polio-like illness has been reported but there is no report on acute transverse myelopathy.

Design, Setting and Participants: We report a patient with WNV myelopathy admitted in a tertiary care teaching hospital, India along with review of the literature.

Findings: A 34 year-old lady presented with fever, headache, diarrhea, seizure, bulbar weakness and quadriplegia for 20 days. Her encephalopathy, bulbar and upper limb weakness improved within few days but flaccid areflexic paraplegia persisted till 6 months with a horizontal sensory level at D3. Electromyography was suggestive of anterior horn cell involvement and somatosensory evoked potential was unrecordable. MRI revealed middle cerebellar peduncle, pons and whole of spinal cord involvement. We could get 11 articles with spinal cord involvement in WNV infection in the medical literature through PubMed search. Their clinical, MRI and electro-diagnostic findings and outcome have been discussed.

Conclusion/Clinical Relevance: Acute transverse myelitis may occur in WNV encephalitis and EMG may be helpful in confirming anterior horn cell involvement and predicting outcome.     

Cervical spinal cord multiple sclerosis: evaluation with 2D multi-echo recombined gradient echo MR imaging

Abstract

Objective: The two-dimensional multi-echo recombined gradient echo (MERGE) technique automatically acquires and sums multiple gradient echoes at various echo times in cervical spine magnetic resonance (MR) imaging. This technique increases the grey–white matter contrast within the spinal cord and should also improve the depiction of cervical cord lesions. The aim of this study was to qualitatively and quantitatively evaluate MERGE imaging compared with T2-weighted fast spin-echo (T2WFSE) imaging for depicting multiple sclerosis (MS) lesions in the cervical cord.

Methods: Nineteen consecutive patients (10 males and 9 females; age range 22–62 years, mean age 43.6 years) with clinically diagnosed MS were examined with cervical spinal cord MR imaging at 3 T including both MERGE and T2WFSE imaging. Qualitative evaluation for MS lesion conspicuity was performed. The quantitative criterion utilized to compare MERGE imaging with T2WFSE imaging was the lesion-to-background contrast-to-noise ratio (CNR).

Results: MERGE imaging showed 79 lesions and missed 1 that was depicted on T2WFSE imaging. T2WFSE imaging showed 46 lesions and missed 34 that were depicted on MERGE imaging. MERGE imaging was markedly superior to T2WFSE imaging in rendering greater lesion conspicuity. In the quantitative evaluation, the lesion-to-background CNR upon MERGE imaging was significantly higher than that upon T2WFSE imaging (P < 0.001, paired t-test).

Conclusions: MERGE imaging in the cervical spinal cord increases detection and conspicuity of MS lesions. Strong consideration should be given to utilizing axial MERGE images in the diagnosis and follow-up study of cervical cord MS.     

Acute transverse myelitis in a 7-month-old boy after diphtheria-tetanus-pertussis immunization

STUDY DESIGN: Case report of a 7-month-old boy, who developed acute transverse myelitis after diphtheria-tetanus-pertussis immunization. OBJECTIVES: To describe the clinical course of acute transverse myelitis in an infant and to review the literature regarding the association of acute transverse myelitis and vaccinations. SETTING: Department of Pediatrics, University of Kentucky, Lexington, Kentucky, USA. METHODS: Case report. RESULTS: Magnetic resonance imaging (MRI) on admission demonstrated diffuse spinal cord edema with increased signal on T-2 weighted images and faint enhancement with gadolinium infusion. Urologic symptoms improved with steroids but motor function was never fully regained. Repeat MRI of the spinal cord several months later showed diminution of cord diameter with resolution of edema and signal abnormality. CONCLUSION: Based on the clinical course and MRI findings, the daignosis of acute transverse myelitis was made. The association of previously received DPT immunization and the genesis of transverse myelitis is explored.