This document presents a case study of a 20-year-old male patient diagnosed with Transverse Myelitis (TM). The patient presented with sudden bilateral lower extremity weakness and loss of sensation that progressed over one month. Investigations including MRI and CSF analysis confirmed the diagnosis of TM. The patient was treated with high-dose steroids, antivirals, antibiotics, and physiotherapy. His symptoms showed signs of gradual improvement over time. The document also provides background information on TM, including causes, pathophysiology, clinical presentation, diagnosis, treatment options and prognosis.

1. Case presentation 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
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3. • Identification
Id:86035
Age: 20
Sex: M
Occupation: policeman
Residence: Arsi
Ethnicity: Oromo
• Chief complaint: bilateral lower extremity of 1
month duration
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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.
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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.
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6. CONT’D
• For the above compliants,
• he visited health center on the 2nd day of onset
of symptoms where he was catheterized , given
IM medication, and on 4th 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.
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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
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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
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9. CONT’D
• GUS: Catheterized, no CVAT, 1400ml/24hrs
UOP
• MSS: no tenderness , deformity
• Integumentary: no rash, pallor, no edema
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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
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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
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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: absent
Meningeal signs: -ve
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13. Localization
• Is it neurologic?
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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
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15. MRI
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16. DDX of TM
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17. DX
• PARAPLEGIA 20 LONGITUDINAL EXTENSIVE
TRANSVERSE MYELITIS + SPINAL SHOCK+UTI
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18. RX
• Dexamethasone 8mg QID
• ACYCLOVIR 800MG PO Q4HR
• ESOEPROLE 40MG IV QD
• UFH 7500IU SC BID
• GENTMYCIN 160MG IV QD, now on 4th day on
meropenem
• BEDSIDE PHYSIOTHERPY
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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
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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
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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.
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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
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23. Pathophysiology
Three hypotheses:
1. Cell mediated autoimmune response
2. Autoimmune vasculitis
3. Direct viral invasion of spinal cord.
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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 pain?
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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.
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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.
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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
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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.
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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
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30. Sample references
• Localization in clinical neurology, 5 ed.
• Harrison’s neurology in clinical medicine 2nd 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
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