Transverse myelitis is an inflammation of the spinal cord. It is a neurological condition in which the inflammation of the spinal cord leads to damage of the nerve fibers causing them to lose their myelin sheath and decrease in their ability to conduct electricity within the nervous system.
Presentation
There are 4 classic features of transverse myelitis,
The presentation can either be acute when it develops within days or subacute when it develops within weeks. Symptoms include lower back pain, sudden paresthesia in the legs which may described by patient as burning, tingling, pricking, or tickling sensations. There is also sensory loss in the lower limbs and paraparesis (partial paralysis of the lower limbs) which may progress to paraplegia (total paralysis of the lower limbs). Sensory defect will also affect the autonomic nervous system causing symptoms like urinary and bowel incontinence. There will be history of muscle spasms, headache, fever, general feeling of unwell and discomfort, and loss of appetite. If the lesion is higher up the spinal cord, respiratory problems may be experienced [6].
Entire Body System
- Fatigue
Konsekvenser i dagligt liv kognitiv nedsättning och fatigue efter transitorisk ischemisk attack Engelsk titel Daily life consequences,cognitive impairment and fatigue after transient ischemic attack Populärvetenskaplig sammanfattning av projektet Objectives [researchweb.org]
We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: August 4, 2019 [patientslikeme.com]
The patient reported a reduction in pain, dyspnea, and fatigue accompanied by an improvement in the quality of sleep and mood. [ncbi.nlm.nih.gov]
[…] and progress rapidly, with muscle weakness on both sides of the body, (if the upper part of the spinal cord is affected, both arms and legs are affected- if the thoracic part is affected, both legs only will be affected), back pain, limb spasticity, fatigue [nicklauschildrens.org]
- Severe Pain
Severe pain suggests worse inflammation. The outcome is split evenly: About one third of people recover. About one third continue to have some muscle weakness and urinary problems (urgency or loss of bladder control). [msdmanuals.com]
Three days later, she returned to the emergency room due to increased severity of pain in the same extremity and a new onset of dyspnoea with chest pain. [caribbean.scielo.org]
One day prior to his admission, he complained severe pain in his neck. Few hours later, he was already unable to stand or use his hands. The mental status had not changed and there was no report of headache or blurred vision. [scielo.br]
She had severe pain in her lower back and epigastrium for half an hour. On admission she was alert and orientated. Her lower limb deep tendon and abdominal reflexes were absent. [adc.bmj.com]
- Chills
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He became ill again on April 26, with fever, chills, sweats, anorexia, mild nonbloody diarrhea, and abdominal pain. There was no hematuria or cough. He was treated orally with chloroquine for a presumptive diagnosis of malaria. [cdc.gov]
She stated that her symptoms initially started with rhinorrhea and chills a week ago. [ncbi.nlm.nih.gov]
- Anorexia
He became ill again on April 26, with fever, chills, sweats, anorexia, mild nonbloody diarrhea, and abdominal pain. There was no hematuria or cough. He was treated orally with chloroquine for a presumptive diagnosis of malaria. [cdc.gov]
Low grade fever was present for 2 days, associated with malaise and anorexia. On examination, he was conscious and co-operative with a pulse rate of 88/min and blood pressure of 110/70 mm Hg. General physical examination was within normal limits. [casereports.in]
Gastrointestinal
- Constipation
Case report: The authors report the case of a ten-year-old boy, with no previous relevant diseases, presenting acute urinary retention, constipation and signs of upper motor neuron lesion. [scielo.mec.pt]
Physical therapy may also be helpful to retrain muscles necessary for improved bladder and bowel control and relief of constipation and urinary retention. [encyclopedia.com]
Bowel and bladder problems — may include an increased frequency of the urge to urinate or have bowel movements, loss of bowel or bladder control (incontinence), difficulty urinating, constipation or the feeling of incomplete bowel evacuation. [nationalmssociety.org]
Band-like sensation across the trunk of the body Bladder and bowel problems, including the need to urinate more frequently, incontinence, or difficulty urinating and constipation. [chop.edu]
This may include needing to urinate more frequently, urinary incontinence, difficulty urinating and constipation. When to see a doctor Call your doctor or get emergency medical care if you're experiencing signs and symptoms of transverse myelitis. [mayoclinic.org]
- Loss of Appetite
Transverse myelitis can cause low back pain, spinal cord dysfunction, muscle spasms, a general feeling of discomfort, headache, loss of appetite, and numbness or tingling in the legs. Almost all patients develop leg weakness. [medicinenet.com]
There will be history of muscle spasms, headache, fever, general feeling of unwell and discomfort, and loss of appetite. If the lesion is higher up the spinal cord, respiratory problems may be experienced. [symptoma.com]
[…] of appetite Bladder and bowel control issues Once they start, symptoms can get worse within hours. [webmd.com]
Additional symptoms that have been reported with TM include: Muscle spasms A general feeling of discomfort Headache Fever Loss of appetite Breathing difficulties Sexual dysfunction Depression Anxiety The symptoms experienced are dependent on the part [verywellhealth.com]
Paraparesis often progresses to paraplegia (paralysis of the legs and lower part of the trunk) Many patients also report experiencing muscle spasms, a general feeling of discomfort, headache, fever, and loss of appetite. [mytm.ca]
- Fecal Incontinence
Key points Acute widespread neurologic deterioration, particularly involving urinary and fecal incontinence and para- or tetraparesis in a patient with systemic lupus erythematosus should arouse suspicion for longitudinally extensive transverse myelitis [cmaj.ca]
Deficits may progress over several more days to a complete transverse sensorimotor myelopathy, causing paraplegia, loss of sensation below the lesion, urinary retention, and fecal incontinence. [merckmanuals.com]
Skin
- Formication
On the fifth postoperative day, the patient developed signs of paralytic ileus, associated with formication and progressive paresis in the lower extremities. He had fever and complained of severe abdominal and lumbar pain. [signavitae.com]
Musculoskeletal
- Muscle Spasm
Transverse myelitis can cause low back pain, spinal cord dysfunction, muscle spasms, a general feeling of discomfort, headache, loss of appetite, and numbness or tingling in the legs. Almost all patients develop leg weakness. [medicinenet.com]
Medication for symptoms and complications: You might get drugs to relieve muscle spasms, help control your bladder or bowels, ease stiffness, manage depression, and help with sexual problems. [webmd.com]
Motor involvement is characterized by limb weakness, stiffness and muscle spasms. If the upper spinal cord is involved then respiratory function may be impaired. [orpha.net]
- Leg Weakness
[…] disfunction typically evolves orver hours to days and reaches a nadir within 3 weeks neuropathic pain aching, deep pain in midline or dermatomal pain radicular or lancinating or sensation of burning or itching gives clue to anatomical level of lesion leg [aic.cuhk.edu.hk]
The clinic includes limb and leg weakness, sensory disturbance, bowel and bladder dysfunction, back and radicular pain. [medicoebambino.com]
Almost all patients develop leg weakness of varying degrees of severity. Fewer will experience arm problems. Pain and temperature appreciation are lessened in most patients. [brainfoundation.org.au]
Symptoms include back pain followed by ascending weakness in the legs. There is no cure. Many patients are left with permanent disabilities or paralysis. [medicinenet.com]
- Muscle Cramp
I have pain right between my shoulder blades that flares up from time to time, like a muscle cramp with a vengeance. The pain in my arm also flares up from time to time. My right leg does not feel cold or pain. [barbarah.wordpress.com]
Your provider might advise you to call if you have problems such as: Skin sores or infections Trouble breathing Fever or other signs of infection Trouble urinating regularly or having severe constipation Severe muscle cramps or spasms Increasing pain [urmc.rochester.edu]
Your provider might advise you to call them if you have problems such as: Skin sores or infections Trouble breathing Fever or other signs of infection Not urinating regularly or having severe constipation Severe muscle cramps or spasms Increasing pain [saintlukeskc.org]
- Arthralgia
When the diagnosis was originally made at the age of 14 years, the patient had arthralgia, rash, nephritis, nasal ulcers and multiple biochemical markers consistent with systemic lupus erythematosus. [cmaj.ca]
The patient denied other extra-neurological manifestations of Lyme disease, such as arthralgia or erythema migrans, and had no known history of a tick bite. Treatment with minocycline 100 mg twice a day for positive Lyme antibody was initiated. [karger.com]
Common pediatrics examples of this situation are inability to walk due to calf pain secondary to acute viral myositis, pyogenic arthritis-related arthralgia ( e.g ., gonococcal arthritis in teenagers), nursemaid's elbow, or bone pain secondary to osteomyelitis [jped.elsevier.es]
- Muscular Atrophy
Doug was the global lead for a series of programs in Alzheimer’s disease, Amyotrophic Lateral Sclerosis (ALS) and Spinal Muscular Atrophy (SMA). Doug led the team that developed the drug Spinraza, now approved for SMA. [myelitis.org]
Urogenital
- Incontinence
Symptoms of TM include sudden onset of lower back pain, muscle weakness, or abnormal sensations in the toes and feet which can rapidly progress to more severe symptoms, including paralysis, urinary incontinence, increased urinary urge, urinary incontinence [cureus.com]
We describe a middle-aged man who presented with dengue fever and in whom weakness of the bilateral lower limbs and urinary incontinence developed on the third day of fever. [ncbi.nlm.nih.gov]
Clinical manifestations include motor weakness, sensory loss, and incontinence. (Adams et al., Principles of Neurology, 6th ed, pp1242-6) Svenska synonymer Inga svenska synonymer finns. [mesh.kib.ki.se]
- Sexual Dysfunction
Snapshot A 37-year-old male presents with lower extremity numbness, weakness, and sexual dysfunction. His symptoms began 2 days prior, and has progressively worsened. Medical history is significant for pneumonia caused by Mycoplasma pneumoniae. [medbullets.com]
Sexual dysfunction, a common complication of transverse myelitis. Men may experience difficulty achieving an erection or reaching orgasm. Women may have difficulty reaching orgasm. [mayoclinic.org]
Autonomic anomalies include sexual dysfunction, urinary urge/retention and bowel urgency/retention. [orpha.net]
- Urinary Urgency
An otherwise healthy 28-year-old woman presents with progressive weakness for the past 3 days, numbness below her breasts, and urinary urgency. Neck flexion triggers an electrical sensation that radiates to the coccyx. [nejm.org]
Another one-third show only fair recovery and are left with significant deficits, such as spastic gait, sensory dysfunction, and prominent urinary urgency or incontinence. [sharecare.com]
About one third of patients recover, one third retain some weakness and urinary urgency, and one third are bedbound and incontinent. Multiple sclerosis eventually develops in about 10 to 20% of the patients in whom the cause is initially unknown. [merckmanuals.com]
Neurologic
- Tingling
Most have some numbness, tingling, or a burning sensation in their back, belly, arms, or legs. Almost all lose some bladder control. How much of your body is affected depends on which part of your spinal cord has the problem. [webmd.com]
There are four classic symptoms of TM, including: Weakness in the arms and/or legs Sensory symptoms such as numbness or tingling Pain and discomfort Bladder dysfunction and/or bowel motility problems. [kennedykrieger.org]
There are four classic symptoms of transverse myelitis: weakness in the arms/legs sensory symptoms such as numbness or tingling pain and discomfort bladder dysfunction and/or bowel motility problems The distribution of those symptoms may be symmetric [hopkinsmedicine.org]
Symptoms include lower back pain, sudden paresthesia in the legs which may described by patient as burning, tingling, pricking, or tickling sensations. [symptoma.com]
Transverse myelitis can cause low back pain, spinal cord dysfunction, muscle spasms, a general feeling of discomfort, headache, loss of appetite, and numbness or tingling in the legs. Almost all patients develop leg weakness. [medicinenet.com]
- Paresthesia
C3 Yes No MS F, 26 Pain, paresthesia, weakness, urinary retention Medulla-C5 No Yes ADEM F, 33 Paresthesia, weakness C3–C6 No No ADEM F, 36 Paresthesia, paraparesis, urinary incontinence C1–C4 No Yes NMO M, 54 Pain, stiffness, paresthesia, paraparesis [hindawi.com]
Soon after, the patient presented to the emergency department with symptoms of bilateral paresthesia of the lower limbs which ascended to the pelvis. After a thorough work up and imaging via MRI a diagnosis of transverse myelitis was made. [ncbi.nlm.nih.gov]
We report a case of a 13-year-old girl affected by transverse myelitis who rapidly developed leg paresthesia and weakness, difficulty in deambulation, sensor and sphincter deficits. [medicoebambino.com]
About one-third of people affected with TM experience good or full recovery from their symptoms; they regain the ability to walk normally, and experience minimal urinary or bowel effects and paresthesias. [sharecare.com]
- Headache
She had a low-grade fever and headache without other clinical neurological abnormalities while at our hospital. Cerebrospinal fluid (CSF) showed mononuclear pleocytosis. Other laboratory tests indicated no apparent abnormalities. [ncbi.nlm.nih.gov]
The most seen neurological complication of Neuro-Behçet syndrome is headache. In Behçet\'s syndrome if the neurological symptoms are not completely occur, to diagnose neuro-Behçet may be very difficult. [atif.sobiad.com]
Transverse myelitis can cause low back pain, spinal cord dysfunction, muscle spasms, a general feeling of discomfort, headache, loss of appetite, and numbness or tingling in the legs. Almost all patients develop leg weakness. [medicinenet.com]
- Hyperreflexia
Clinically these patients exhibited hyperreflexia and had rapid improvement with immunotherapies. [ncbi.nlm.nih.gov]
Examination reveals moderate paraparesis with hyperreflexia, a left extensor plantar response, impaired vibratory and proprioceptive sensation, and a sensory level at T6. [nejm.org]
Clinical presentation Typical presentation • Prior history of fever (nonspecific viral illness) • ATM, the onset of spinal cord dysfunction usually progress in 4 hours to 21 days, the patient's signs usually plateau and evolve toward spasticity/hyperreflexia [slideshare.net]
Physical examination revealed diffuse hyperreflexia but normal strength in all 4 extremities. Sensation was intact in the arms but decreased to light touch, vibration, and proprioception in the legs bilaterally. [hindawi.com]
- Burning Sensation
Most have some numbness, tingling, or a burning sensation in their back, belly, arms, or legs. Almost all lose some bladder control. How much of your body is affected depends on which part of your spinal cord has the problem. [webmd.com]
[…] in (depending on which part of the cord is involved) like numbness, tingling or a burning sensation may be felt in arms or feet. [nicklauschildrens.org]
Symptoms include numbness, tingling, a burning sensation and an increased sensitivity to touch, cold and heat. It also results in weakness of the arms and legs which can range from one limb feeling slightly heavy to complete paralysis. [isrctn.com]
Pain in the back, extremities, or abdomen, as well as tingling, numbness, burning sensations (paresthesias), are common Sexual dysfunction is also the result of sensory and autonomic involvement. [rarediseases.org]
Workup
- Radiological tests are important in diagnosis to rule out other causes of the experienced symptoms or an underlying cause of this condition. An MRI is done to examine structural damage to the brain or spinal cord, like spinal cord compression which could also produce similar symptoms [7]. The brain MRI may detecting underlying causes like multiple sclerosis. A contrast CT scan is done when an MRI is not available [8].
- Various blood tests are also done to rule out other underlying conditions like HIV, vitamin B12 deficiency, and systemic lupus erythematosus.
- A lumbar puncture will reveal increased white blood cells in case of an infection and can be used to look for disease markers.
- If no specific cause can be gotten from these tests, the patients is said to have idiopathic transverse myelitis [9].
Microbiology
- Borrelia Burgdorferi
We report a case of a 66-year-old male, with a subacute extensive transverse myelitis, secondary to Borrelia burgdorferi infection. The patient underwent antibiotic therapy filed for neuroborreliosis with a good clinical outcome. [ncbi.nlm.nih.gov]
We reviewed the medical literature and analyzed the clinical features of pediatric patients with Borrelia burgdorferi -related TM. © 2015 S. [karger.com]
Other exams could be required to sort differential diagnosis to other TM etiologies as stains and cultures, CSF polymerase chain reaction (for viruses and Borrelia burgdorferi ), serology, blood cultures and also chest radiograph/CT [ 9 ]. [omicsonline.org]
Treatment
- The treatment for this condition is designed to manage symptoms and reduce spinal cord inflammation as there are no definitive treatments. Intravenous steroids are used soon after diagnosis to reduce inflammation and improve neurological recovery. Steroids that might be used are methylprednisolone and dexamethasone.
- Plasma exchange therapy is instituted in those with moderate to severe disease and in those who don’t respond to steroid therapy.
- Other immunomodulatory treatment like intravenous cyclophosphamide can be used in patients that do not respond to the above treatments.
- The most critical part of management involves maintaining the physiological functioning of the patient.
Prognosis
Recovery from this condition may begin from anytime between 2 to 12 weeks and lasts for up to 2 years. If there is no improvement within the 6 months, then complete recovery is unlikely. About one-third of patients experience full recovery, the other one-third experience partial recovery while the last one-third experience no recovery at all, and will depend on others for basic daily functions. Aggressive treatment and physical therapy will help improve outcomes. Research has shown that if symptoms start rapidly, prognosis will most likely be bad [5].
Etiology
There are several causes of transverse myelitis. Known causes are optic neuritis and multiple sclerosis. It could also be caused by aortic dissection which extends to the spinal arteries as well as viruses like cytomegalovirus, herpes simplex, HIV, Epstein-Barr virus, rabies, enteroviruses and human T-cell leukemia virus. Bacterial infections like tuberculosis, syphilis and Lyme borreliosis have also been implicated along with conditions like paraneoplastic syndrome, and vascular causes like thrombosis of spinal artery, spinal arteriovenous malformations and vasculitis caused by heroin use [2].
Epidemiology
It is a fairly rare condition with the incidence thought to be up to 8 new cases per million per year. It has a bimodal peak age incidence occurring mostly between 10 – 19 years and 30 – 39 years, although it may occur at any age. About 25% of transverse myelitis patients are children and it has no familial association. It has no gender predilection. Most cases are monophasic, occurring just once, but there is recurrence in a minute number of patients and this is mostly due to a predisposing underlying illness [3].
Pathophysiology
- Multiple sclerosis is an autoimmune disease that occurs when T-cells are activated against unknown antigen which produces a cascade of inflammation that leads to demyelination and also axonal loss.
- Optic neuritis on the other hand involves the B-cells. These B-cells produce a substance, anti-aquaporin-4 antibodies which activate the complement system and cause the nerves to lose their myelin sheaths.
- Most idiopathic transverse myelitis are para-infections which has led to the belief that the immune response against the offending organism causes an autoimmune attack on myelin and some other antigens in the spinal cord. Mechanisms of injury could be molecular mimicry, where T-cells or antibodies found on these infectious agents cross-react with those in the central nervous system. Another mechanism could be a super-antigen response by the offending organism [4].
Prevention
There is no known way to prevent the primary attack. Recurrent attacks can be prevented with the use of immunosuppressants [10].
Summary
The origin of the name of this disorder is derived from the Greek word myelos which means spinal cord and the suffix –itis which means inflammation. Transverse implies that it spans the thickness of the cord. Nerve fibers are responsible for conducting electrical impulses and the myelinated fibers conduct these impulses better. In transverse myelitis, these myelin sheaths are destroyed [1].
Patient Information
Definition: Transverse myelitis is a disease of the spinal cord in which the nerves lose their ability to conduct electrical impulses leading to loss of many important daily nervous functions.
Cause: It can be caused by one of several autoimmune diseases. It can also be due to viral and bacterial infections. Some disorders of the arteries have also been known to cause it and it may also be brought about by heroin use.
Symptoms: Symptoms include pain of the legs as well as tingling, numbing and tickling sensations. There is also weakness of the leg muscles which may graduate to full paralysis. There will be loss of bladder and bowel function and in some patients, there will be respiratory difficulty.
Diagnosis: This is done with imaging techniques like MRI and CT scans which will show lesions of the brain and/or spinal cord. Blood tests will also be done to check for underlying diseases and part of the cerebrospinal fluid will be checked.
Treatment: This condition has no known cure but steroids are used to manage the inflammatory process. Plasma exchange therapy is used in patients who don't respond to steroids. Cyclophosphamide can be used in severe cases that don’t respond to any of the above.
References
- Altrocchi PH. Acute Transverse Myelopathy. Arch Neurol 1963; 9:111.
- Borchers AT, Gershwin ME. Transverse myelitis. Autoimmun Rev 2012; 11:231.
- Paine RS, Byers RK. Transverse myelopathy in childhood. AMA Am J Dis Child 1953; 85:151.
- Torabi AM, Patel RK, Wolfe GI, et al. Transverse myelitis in systemic sclerosis. Arch Neurol 2004; 61:126.
- Christensen PB, Wermuth L, Hinge HH, Bømers K. Clinical course and long-term prognosis of acute transverse myelopathy. Acta Neurol Scand 1990; 81:431.
- Oh DH, Jun JB, Kim HT, et al. Transverse myelitis in a patient with long-standing ankylosing spondylitis. Clin Exp Rheumatol 2001; 19:195.
- Bakshi R, Kinkel PR, Mechtler LL, et al. Magnetic resonance imaging findings in 22 cases of myelitis: comparison between patients with and without multiple sclerosis. Eur J Neurol 1998; 5:35.
- Wolf VL, Lupo PJ, Lotze TE. Pediatric acute transverse myelitis overview and differential diagnosis. J Child Neurol 2012; 27:1426.
- Bruna J, Martínez-Yélamos S, Martínez-Yélamos A, et al. Idiopathic acute transverse myelitis: a clinical study and prognostic markers in 45 cases. Mult Scler 2006; 12:169.
- Tippett DS, Fishman PS, Panitch HS. Relapsing transverse myelitis. Neurology 1991; 41:703.