This document discusses various infectious causes of myelopathy or spinal cord dysfunction. It covers viral, bacterial, parasitic and fungal pathogens that can directly invade or cause inflammatory changes in the spinal cord. Key points include discussions of viruses like HIV, HTLV-1, poliovirus, West Nile virus and herpes viruses as well as bacteria like syphilis, tuberculosis, Lyme disease and pyogenic organisms. Parasitic infections involving the spinal cord from organisms such as schistosomiasis, toxoplasmosis and neurocysticercosis are also outlined. Clinical presentations, diagnostic approaches and treatment options are provided for many of the infectious etiologies of myelopathy.

1. INFECTIOUS MYELOPATHY
DR.SARATH MENON.R, MD(Med.),DNB(Med.),MNAMS
DM RESIDENT,
DEPT. OF NEUROSCIENCES
AIMS,KOCHI.

2. INTRODUCTION
 Infections and secondary inflammatory changes
play an important role
 Direct neuronal invasion
 Molecular mimicry
 Myelopathy- spinal cord dysfunction of any
etiology ,intrinsic or extrinsic

3. PRESENTATION
 Acute transverse myelitis
 Acute flaccid paralysis- AHC, motor roots

4. APPROACH
 History & physical examinations
 Tempo of illness
 Exposure
 Demographic- endemicity
 Host immune status
 Ancillary test
 Diagnosis & Rx

6. PARAINFECTIOUS ETIOLOGY
 30 -60% infective myelopathy preceeded by
systemic infectious process
 Molecular mimicry-
cross reactivity with host antigen in spinal cord
 Usually 2-4 wks after infection
 Dx- CSF IgG index,OCB
Serology & specific antigen in csf /serum
 Rx-
Iv steroid
Refractory cases- IVIG,cyclophosphamide or
rituximab.

7. CAUSATIVE AGENTS
 Viral
 Bacterial
 Parasitic
 Fungal

9. RETRO VIRUSES- HIV
 CNS – lymphocytes,microglia
 Crosses BBB
 Neurotoxicity by viral proteins
 Chronic pro inflammatory state
 CD4 < 200- HIV – vacuolar myelopathy

10. HIV –VACUOLAR MYELOPATHY
 Slow progressive,painless myelopathy
 LL weakness,gait difficulties,spasticity,erectile
dysfunction,mild paresthesia
 Urge incontinence,urgency- later
 Impaired proprioception
 LL disproportionately affected.
 Diagnosis of exclusion in HIV + pts.
 Acute presentation,spinal level ,prominent pain ,UL
prominently involved- alternate diagnosis
 D/D- oppurtunistic infection,neoplasms,VB12 def.

11.  Imaging-
Usually normal.
Spinal cord atrophy
Findings similar SACD
 Microscopy-
spongy,vacuolation of myelin
lipid laden macrophages
 Rx-
HAART reduced incidence
No response to ART,B12 or IVIG,steroids

13. 13
HIV-related myelopathy. Vacuolar changes
are evident in the lateral and posterior
columns of the thoracic spinal cord.

15. HTLV-1 (HAM/TSP)
 4% HTLV-1 will develop
 Female predominance
 CD8 + Tcell neurotoxicity or molecular mimicry
 Clinical features
- insidious ,slow progression
- LL spasticity
- prominent bladder/bowel involvement
- UL weakness insignificant

16.  Diagnosis
- Clinical,demographic,serology
- csf- lymphocytic pleocytosis,OCB+
Confirmation- Western blot
PCR- peripheral blood- distinction & viral load
Imaging
-Focal T2 Hyperintensity in lower cervical cord
-contrast enhancement+
- close d/d to MS
- cervical/thoracic cord atrophy

17. TREATMENT
 No effective clinical trials to date.
 Steroids
 INF-alpha, cyclosporine,azathioprine- effective
early – limited evidence
 HAART

18. ENTEROVIRUSES
 Ubiquitous RNA virus
 Produce acute flaccid paralysis
 Poliovirus
- AHC affection
- Subsaharan Africa,middle east,Indian subcontinent
- Fever,menigismus,asymmetric flaccid paralysis of LL
proximal > distal over 2 days
- Post polio syndrome
- Slow progressive recrudescence
- Severity of initial disease

19. ENTEROVIRUS 71- EV 71
 AFP similar to polio
 Asia –pacific
 Children
 Fever ,rash – paralysis over 3-5 days
 Mri= T2 hyperintensity in lower brainstem,cerebellum
 CSF- lymphocytic pleocytosis
 No specific rx
 IVIG -tried

20. FLAVIVIRUS- WEST NILE VIRUS
 Polio-like paralysis
 Mosquito vector
 Fever—myelitis—over 2-8 days
 Flaccid paralysis, respiratory,bladder +
 Risk factor
Age > 50 yrs,immunosuppression
WNV – directly affect AHC

21. 21
West Nile virus encephalomyelitis.
A, Crosssection
of the cervical spinal cord showing
anterior horn–predominant inflammatory
infiltrate (arrows).
.
B, Higher magnification shows
destruction of anterior horn neurons with
perivascular
lymphocytic cuffing seen at lower right;
arrow indicates a
remaining neuron

22.  Diagnosis
-peripheral leukocytosis,thrombocytopenia,transaminitis
CSF- PMN /mononclear pleocytosis,elev.protein,sug-nl
- IgM –sensitive/specific
- serology
-Spinal cord imaging-normal
- Rx
- Supportive,no specific
- anecdotal- steroids

23. RABIES
 2/3rd –furious/encephalitic,1/3rd –dumb/paralytic
 Paralytic-
GBS like presentation—encephalopathy—death
 Considered in exposure to animal bite esp.bat
 PCR- Skin biopsy from nape of neck-specific
 Serology
 Virus amplification from skin,saliva,CSF
 Supportive rx.
 Prophylaxis

24. HERPES VIRUSES-HSV1&2
 HSV1 &2 – myelitis
 HSV-2 related myelitis-adults
 Elsberg syndrome-reactivation of HSV-2
inflammation in dorsal roots + spinal cord = radiculomyelitis
 C/f :
- subacute lower extremity weakness may ascend
- Numbness or tingling in lumbosacral dermatome
- Urinary retention
Acute necrotising myelopathy- severe form seen in
immunocompromised

25.  Flaccid paraplegia+ areflexia
 Diagnosis
- CSF-lymphocytic pleocytosis with raised protein
 Necrotizing myelitis- PMN leukocytosis
 CSF-PCR amplification of DNA
 Imaging
- Spinal cord edema
- T2 hyperintensity+CE of radicular roots & cord
 Rx
- Iv acyclovir x 14 days f/b oral acyclovir /valacyclovir
- Steroids –role uncertain
- Complete recovery is posssible
- 20% cases,recur

26. VZV
 Myeloradiculitis on reactivation-immunocompromised
 Necrotising vasculitis + demyelination
 Zoster preceeds, cases with no rash
 Asymmetric paraparesis + sensory loss- days to wks
 CSF-
Mononuclear pleocytosis ,elevated protein
Anti-VZV IgM assay in CSF-sensitive
PCR- rapid
Imaging- T2 hyperintense in cord = dermatome
Rx
iv acyclovir + steroids

27. CMV
 Imunocompromised- HIV – CD4<100cells/microL
 Lumbosacral polyradiculomyelitis-
supf.meningitis-> nerve roots & spinal cord
 Necrotizing myelitis
 Imaging-
cord edema+root edema+ CE
meningeal thickening+clumping of roots
CSF-
PMN pleocytosis+elev.protein+ low sugar
Rx
IV ganciclovir+ foscarnet
Poor prognosis

28. EBV
 Children / young adults
 Immunocompromised –transplant
 Spectrum – aseptic meningitis
meningoencephalitis
cranial/peripheral neuritis
GBS & myelitis
Myelitis- 2-3 weeks after primary infection
flaccid paraparesis,sensory level,bladder+
CSF-
mononuclear pleocytosis,elev.protein,sugar-nl

29.  Serology –EBV DNA
 CSF-EBV DNA PCR
 Imaging-
T2hyperintensity+ce+nerve thickening
Rx
- Acyclovir-little effect on clinical course
- steroids

31. BACTERIAL- SYPHILIS
 Meningovascular-cord infraction-endarteritis-rare
 Tabes Dorsalis
 Post antibiotic era- less incidence
 c/f-
subacute/chronic – sensory ataxia+
loss of vibration,joint position
lancinating pain+
hyperreflexia,charcot joint,AR pupil
Imaging-
cord atrophy
non enhancing T2 hyperintensity-posterior cord

32. SYPHILIS-OTHER FORMS OF MYELOPATHY
 Hypertrophic pachymeningitis
 Spinal cord Gumma
 AHC
 Syingomelia
 Aortic aneurysm –sec AHC
 Charcot vertebra-cord compression

33. SYHILITIC MENINGOMYELITIS
 Current era, most common spinal cord d/s
 Men-25-40 yrs
 Avg.6yr after infection
 Progressive spastic ,asymmetric paraparesis
 Imaging-
T2 hyperintensity central cord +CE

34. DIAGNOSIS & RX
 Peripheral serology+ CSF evaluation
 VDRL & RPR- sensitive in early
 TP-FAB- specific
 CSF- mild inflammatory
- VDRL,FAB
Rx
Inj.Penicillin aqueous -12-24 mu q4h x 10-14 days
Jarisch-Herxheimer reaction
(iv steriods-premptively)

35. LYME DISEASE
 Ixodes tick-endemic North America,Europe,Asia
 Erythema migricans-initial lesion
 Classic triad- facial palsy,aseptic meningitis,painful
radiculitis
 Bannworth synd.-acute transverse myelitis-painful
 Chronic,progressive myelopathy- other form
 Diagnosis
-clinical history
-ELISA/Western blot
-CSf- Lyme specific IgM
-MRI- T2 hyperintensity+CE-root,meninges
 Rx-
IV Ceftriaxone-14-28 days+ steroids

36. TUBERCULOSIS
 MC myelopathy- Pott’s disease
 Vertebral venous system
 Anterior segment of thoracic & lumbar spine-collapse
 Other forms-
- intramedullary/intradural tuberculomas-
(S/A myelopathic symptoms).
- granulomatous myeloradiculitis-
(rapid progressive rad.pain,paresthesia,flaccid
weakness,babinski+ ,bladder+)
- spinal artery vasculitis+ cord infarction
- ADEM
- Cord compression- vertebre,granulating tissue

37. DIAGNOSIS
 CSF- lymphocytic pleocytosis,low sugar,very high protein
AFB,TB cultures
 Mantaux test- + in 40%
 MRI (Pott’s)–T1 hypo +T2 hyper +CE
Vertebre collapse+ cord compression
 Granulomatous myeloradiculitis-
CE+ meningeal thickening +spinal roots
 Tuberculomas-
CE+ T1 hypointense ring +T2 hyperintense central

38. RX
 2 month HRZE/S+ 7-10 Month HR
 Vertebral disease- surgical option
 Lumbar disease-better prognosis

39. PYOGENIC BACTERIA
 Vertebral osteomyelitis- collapse+ epidural abscess
 Intramedullary abscess- hematogenous seeding+
 Epidural abscess
- osteomyelitis- hematogenous
- Local soft tissue,viscera,instrumentation ant.epidural
- Direct seeding- post.epidural
- Risk factors+
- Thoracic +

40.  C/F-
- Focal back pain+ muscle spasms
- Fever
- MC- S.aureus > Streptococcus > GNB
Diagnosis-
ESR,CRP
Blood culture-+ 60%
Imaging
LP –contraindicated
Rx
- Drainage
- Iv antibiotics

42. OTHER BACTERIAL MYELOPATHY
 Bartonella- myelitis & Brown –Sequard syndrome
 Whipple disease-
 Parainfectious-
Mycoplasma
Pertussis

44. PARASITIC MYELOPATHIES
 Schistosomiasis
 Central America & Africa
 Retrograde migration of eggs ffrom portal system to
epidural venous plexus
 Subacute- low back ache- paraparesis-sensory level-
bladder/bowel++
 T11 –L1 & Cauda equina
 MRI-
-Cord enlargement
- intramedullary T2 hyperintensity
- lower thoracolumbar cord,conus,cauda CE

45. DIAGNOSIS
 3 features
-Lower spinal cord or cauda
-Evidence of infection(ova in stool/urine,rectal
biopsy,serology)
-Exclusion of other causes
 Peripheral Serology- ELISA,IF
 CSF tests specific- Monoclonal antibodies or PCR
 Tissue biopsy- gold standard
(avoided in CNS disease).

46. RX
 Praziquantel
 Concurrent steroids
 Rarely, decompression- medically refractory

47. OTHER PARASITES
 Toxoplasma gondii-
-Advanced HIV
-Parenchymal + spinal cord mass lesions
-Peripheral IgG+
- CSF-PCR(spf)
 Rx-
pyrimethamine + sulfadiazine /clindamycin
folinic acid

48. NEUROCYSTICERCOSIS
 1.2 %-5.8% cases involve spinal cord
 Subarachnoid
 Subarachnoid cysts migrate from basal cisterns
 75% cases – intracranial NC
 Csf- high proten + eosinophilia
 Rx
- albendazole + steroids
- rarely,decompression.

49. HYDATID CYST-ECHINOCOCCUS
 Spinal rare
 Vertebrae,extradural or paraspinal
 Cysts in other sites+
 Large- mass effect,bony destruction,inflammatory
response
 Imaging-cysts
 Serology
 Rx-
albendazole
surgical
Recurrence- norm

50. OTHER PARASITES
 Gnathostoma spinigerum
 Angiostrongylus cantonensis

51. FUNGAL CAUSES
 Immunocompromised
 Aspergillus,cryptococcus
 Spinal myelopathy
- epidural abscess
- c/c arachnoiditis
- intramedullary granulomas
- frank myelitis
- vasculitis + cord infarction.

54. APPROACH
 Clinical –
- Onset- Acute vs Subacute Vs Chronic
- Progression
- Painful vs painless
- Sensory level
- Bladder/Bowel+
 CSF analysis
 Imaging

55. ACUTE FLACCID PARALYSIS
 Polio
 Enteroviruses
 West NileV
Leukomyelitis-(Acute)
 Herpes
 CMV
 Borellia- rare
 EBV
 Rabies

56. LEUKOMYELITIS (SUBACUTE-CHRONIC)
 Treponema
 Mycoplasma
 Tuberculosis
 HIV/HTLV-1

59. Thank you