There are 4 classic features of transverse myelitis,

• Weakness of the legs and arms
• Pain
• Sensory alteration 
• Bowel and bladder dysfunction

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].

• Swelling

  The symptoms of ATM can come on quickly and depend on where in the spine the swelling occurs. If the swelling is in the lower back, then symptoms can include back pain, weakness of both legs and bowel and bladder problems. [gosh.nhs.uk]

  Unilateral meningeal hyperintensity was seen on T2 fluid-attenuated inversion recovery MRI with associated cortical swelling and gadolinium enhancement of the cortical layer. [ncbi.nlm.nih.gov]

  There is no swelling and no enhancement. It does not look like MS or tumor, so we are thinking ATM - acute transverse myelitis. [radiologyassistant.nl]

• 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]

• Pallor

  […] may be present, in which cases CNS infection need to be ruled out; • point tenderness over the spine may point to trauma or infection • Neurologic examination directed to • visual acuity and color vision • funduscopic examination for optic nerve head pallor [slideshare.net]

  There was no pallor, icterus, cyanosis & lymphadenopathy. His vital parameters were well within normal limits. Systemic examination also did not reveal any abnormality. [alliedacademies.org]

  In MS, very often pallor of the optic disc detected on clinical examination or a delayed visual evoked response draws attention to the underlying OPN. [doi.org]

• 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]

• 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]

• Neck Pain

  Otherwise, Rabinovici says, "Neck pain is not going to be any more serious than a pain in the neck." In some instances, transverse myelitis will lead to another autoimmune disease, like multiple sclerosis or lupus, according to Balabanov. [self.com]

  A 7-year-old girl presented with complaints of neck pain, spout-style vomiting, cough, shortness of breath, and acute paraparesis with sensory and sphincter disturbance. The patient was intubated because of increased respiratory distress. [ncbi.nlm.nih.gov]

  These are possible symptoms: Back or neck pain Weakness in arms or legs Abnormal feelings in the legs, such as burning, tingling, or pricking Loss of bladder or bowel control Heightened sensitivity to touch Where in the body these symptoms occur depends [stlouischildrens.org]

  Common symptoms are back or neck pain, weakness or sensation changes in the arms or legs, or loss of bladder or bowel control. Treatment with steroids or other medicines doesn't cure transverse myelitis. But it might relieve symptoms. [urmc.rochester.edu]

• Numbness of the Feet

  A bandlike tightness around the chest or abdomen, weakness, tingling, numbness of the feet and legs, and difficulty voiding develop over hours to a few days. [merckmanuals.com]

• Myalgia

  Practice CMAJ February 21, 2012 184 (3) E197-E200; DOI: https://doi.org/10.1503/cmaj.101213 An 18-year-old man with a three-year history of well-controlled systemic lupus erythematosus experienced new-onset fatigue, malaise and diffuse myalgia before [cmaj.ca]

  Patients with acute schistosomiasis, or the Katayama syndrome, which usually begins with the deposition of schistosome eggs into host tissues, can present with fever, malaise, myalgia, fatigue, nonproductive cough, diarrhea (with or without blood), hematuria [doi.org]

• 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]

• Suggestibility

  Furthermore, these cases suggest a potential role for approaching how we classify subtypes of transverse myelitis and acute disseminated encephalomyelitis. [ncbi.nlm.nih.gov]

  In the setting of a characteristic brain MRI, the acute partial variant suggests high future risk of developing multiple sclerosis (MS). [bestpractice.bmj.com]

  History may suggest a drug as a cause. [merckmanuals.com]

• 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]

• Urinary Retention

  Keywords : acute urinary retention; acute transverse myelitis; upper motor neuron lesion. [scielo.mec.pt]

  A 35 year-old male Caucasian recently returned from the tropics presented to our hospital with urinary retention and acute paraparesis. After extensive diagnostic workup he was diagnosed with acute HIV infection presenting as transverse myelitis. [ncbi.nlm.nih.gov]

• 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]

• 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]

• Meningism

  We presented this case because coexistence of transverse myelitis and aseptic meningitis is very rare. Anahtar Kelime:Behçet\'s disease, neuro-Behçet, transverse myelitis, aseptic meningitis [atif.sobiad.com]

  Unilateral meningeal hyperintensity was seen on T2 fluid-attenuated inversion recovery MRI with associated cortical swelling and gadolinium enhancement of the cortical layer. [ncbi.nlm.nih.gov]

  […] with mcc 098 Non-bacterial infection of nervous system except viral meningitis with cc 099 Non-bacterial infection of nervous system except viral meningitis without cc/mcc Convert G37.3 to ICD-9-CM Code History 2016 (effective 10/1/2015) : New code [icd10data.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]

• Monoplegia

  A localized deficit, such as facial palsy ( Table 4 ) 36 or monoplegia ( Table 5 ), 3 tends to have a smaller list of etiologies, while a more diffuse deficit, e.g ., paraplegia, hemiplegia, or tetraplegia, will require consideration of many etiologies [jped.elsevier.es]

• 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].

• 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.

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].

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].

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].

• 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].

There is no known way to prevent the primary attack. Recurrent attacks can be prevented with the use of immunosuppressants [10].

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].

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.

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