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Acute Transverse Myelitis


Michael Rubin

, MDCM, New York Presbyterian Hospital-Cornell Medical Center

Reviewed/Revised Feb 2023

Acute transverse myelitis is acute inflammation of gray and white matter in one or more adjacent spinal cord segments, usually thoracic. Causes include multiple sclerosis, neuromyelitis optica, infections, autoimmune or postinfectious inflammation, vasculitis, and certain drugs. Symptoms include bilateral motor, sensory, and sphincter deficits below the level of the lesion. Diagnosis is usually by MRI, cerebrospinal fluid analysis, and blood tests. IV corticosteroids and plasma exchange may be helpful early. Otherwise, treatment is with supportive measures and correction of any causes.

Acute transverse myelitis is most commonly due to multiple sclerosis Multiple Sclerosis (MS) Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more Multiple Sclerosis (MS) ; however, it can occur in patients with vasculitis Overview of Vasculitis Vasculitis is inflammation of blood vessels, often with ischemia, necrosis, and organ inflammation. Vasculitis can affect any blood vessel—arteries, arterioles, veins, venules, or capillaries... read more Overview of Vasculitis , systemic lupus erythematosus (SLE) Systemic Lupus Erythematosus (SLE) Systemic lupus erythematosus is a chronic, multisystem, inflammatory disorder of autoimmune etiology, occurring predominantly in young women. Common manifestations may include arthralgias and... read more Systemic Lupus Erythematosus (SLE) , antiphospholipid syndrome Antiphospholipid Syndrome (APS) Antiphospholipid syndrome is an autoimmune disorder characterized by venous and arterial thrombosis or pregnancy complications (eg, recurrent miscarriage) and persistent autoantibodies to phospholipid-bound... read more , other autoimmune disorders Autoimmune Disorders In autoimmune disorders, the immune system produces antibodies to an endogenous antigen (autoantigen). The following types of hypersensitivity reactions may be involved: Type II: Antibody-coated... read more , mycoplasmal infections Mycoplasmas Mycoplasmas are ubiquitous bacteria that differ from other prokaryotes in that they lack a cell wall. Mycoplasma pneumoniae is a common cause of pneumonia, particularly community-acquired... read more , Lyme disease Lyme Disease Lyme disease is a tick-transmitted infection caused by the spirochete Borrelia species. Early symptoms include an erythema migrans rash, which may be followed weeks to months later by... read more Lyme Disease , syphilis Syphilis Syphilis is caused by the spirochete Treponema pallidum and is characterized by 3 sequential symptomatic stages separated by periods of asymptomatic latent infection. Common manifestations... read more Syphilis , tuberculosis (TB) Tuberculosis (TB) Tuberculosis is a chronic, progressive mycobacterial infection, often with an asymptomatic latent period following initial infection. Tuberculosis most commonly affects the lungs. Symptoms include... read more Tuberculosis (TB) , COVID-19 COVID-19 COVID-19 is a respiratory illness caused by the novel coronavirus SARS-CoV-2. Infection may be asymptomatic or have symptoms ranging from mild upper respiratory symptoms to acute respiratory... read more , or viral meningoencephalitis Encephalitis Encephalitis is inflammation of the parenchyma of the brain, resulting from direct viral invasion or occurring as a postinfectious immunologic complication caused by a hypersensitivity reaction... read more or in patients taking amphetamines, IV heroin, or antiparasitic or antifungal medications. Transverse myelitis occurs with optic neuritis in neuromyelitis optica Neuromyelitis Optica Spectrum Disorder (NMOSD) Neuromyelitis optica spectrum disorder is a demyelinating disorder that predominantly affects the eyes and spinal cord but can affect other structures in the central nervous system (CNS) that... read more (Devic disease), once considered a variant of multiple sclerosis but now considered a distinct disorder.

The mechanism of transverse myelitis is often unknown, but some cases follow viral infection or vaccination, suggesting an autoimmune reaction. Inflammation tends to involve the spinal cord diffusely at one or more levels, affecting all spinal cord functions.

Symptoms and Signs of Acute Transverse Myelitis

Symptoms of acute transverse myelitis may include pain in the neck, back, or head. 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. 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. Occasionally, position and vibration sensation are spared, at least initially.

Acute transverse myelitis occasionally recurs in patients with multiple sclerosis, SLE, or antiphospholipid syndrome.

Diagnosis of Acute Transverse Myelitis

  • MRI and cerebrospinal fluid (CSF) analysis

  • Other tests to identify treatable causes

Diagnosis of acute transverse myelitis is suggested by transverse sensorimotor myelopathy with segmental deficits. Guillain-Barré syndrome Guillain-Barré Syndrome (GBS) Guillain-Barré syndrome is an acute, usually rapidly progressive but self-limited inflammatory polyneuropathy characterized by muscular weakness and mild distal sensory loss. Cause is thought... read more can be distinguished because it does not localize to a specific spinal segment.

Diagnosis requires MRI and CSF analysis. MRI typically shows cord swelling if transverse myelitis is present and can help exclude other treatable causes of spinal cord dysfunction (eg, spinal cord compression Spinal Cord Compression Various lesions can compress the spinal cord, causing segmental sensory, motor, reflex, and sphincter deficits. Diagnosis is by MRI. Treatment is directed at relieving compression. (See also... read more Spinal Cord Compression ). CSF usually contains monocytes, protein content is slightly increased, and IgG index is elevated (normal, 0.85).

A test for a marker for neuromyelitis optica IgG (NMO-IgG)—an autoantibody that targets the astrocyte water channel protein aquaporin-4—is highly specific and helps distinguish neuromyelitis optica Diagnosis Neuromyelitis optica spectrum disorder is a demyelinating disorder that predominantly affects the eyes and spinal cord but can affect other structures in the central nervous system (CNS) that... read more from multiple sclerosis Diagnosis Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more Diagnosis . All patients are also tested for anti-MOG IgG autoantibody, which can help identify patients with myelin oligodendrocyte glycoprotein antibody disease (MOGAD).

Tests for treatable causes should include chest x-ray; PPD (purified protein derivative) for tuberculosis; serologic tests for mycoplasma, Lyme disease, COVID-19, and HIV; erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP); antinuclear antibodies; and CSF and blood Venereal Disease Research Laboratory (VDRL) tests. History may suggest a medication or recreational drug as a cause.

The differential diagnosis of acute transverse myelitis includes other transverse myelopathies due to nutritional deficiencies (eg, deficiency of vitamin B12, folate, zinc, or copper), vascular insufficiency, and intraspinal tumors.

Brain MRI is done; multiple sclerosis develops in 50% of patients who have multiple periventricular T2 bright lesions and in 5% who do not have them.

Treatment of Acute Transverse Myelitis

  • Treatment of the cause

  • Sometimes corticosteroids

Treatment of acute transverse myelitis is directed at the cause or associated disorder but is otherwise supportive.

In idiopathic cases, high-dose corticosteroids are often given and sometimes followed by plasma exchange because the cause may be autoimmune. Efficacy of such a regimen is uncertain.

Prognosis for Acute Transverse Myelitis

Generally, the more rapid the progression is, the worse the prognosis. Pain suggests more intense inflammation. 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.

Key Points

  • Autoimmune and demyelinating disorders, infections, a medication, or a recreational drug can inflame tissues in spinal cord segments, causing transverse myelitis, which may progress to complete transverse sensorimotor myelopathy.

  • Do MRI of the spinal cord, CSF analysis, testing for neuromyelitis optica IgG, anti-MOG IgG autoantibody, and other tests for treatable causes (eg, infections).

  • Treat the cause if identified, and if no cause is evident, consider corticosteroids and plasma exchange.

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