II. Definitions
- Myelitis
- Spinal Cord Inflammation of various causes including Viral Infections, toxins, autoimmune or vascular conditions
- Findings include motor weakness, sensory changes (Paresthesias, numbness, pain) and Urinary Incontinence
- Transverse Myelitis
- Spinal cord inflammation of a transverse segment of the cord with demyelination and necrosis
- Myelitis findings occur below the segment of spinal cord involvement
III. Epidemiology
- Incidence (rare): 1.3 to 4.6 per million people
- Ages
- Most common in children and young adults
IV. Pathophysiology
- Spinal cord inflammation due to autoimmune, inflammatory, vascular or infectious causes
- Myelitis may be unilateral or bilateral, and may effect only some long tracts but not others
- The terms Myelitis, Transverse Myelitis and Acute Transverse Myelitis are used interchangeably
- The adjective transverse only describes the distribution, but the causes and management are similar
V. Findings: Symptoms and Signs
- See Spinal Cord Syndrome
- Timing
- Onset over hours to days
- Progression over days to weeks
- Distribution
- Myelitis is typically bilateral but may be unilateral
- Myelitis may only cause sensory and motor changes at a few spinal levels (sparing lower cord levels)
- Myelitis may effect only some long tracts but not others
- Motor weakness
- Leg flexors and arm extensors are preferentially affected (pyramidal distribution)
- Sensory changes
- Paresthesias
- Typically initial sensory symptom
- Paresthesias ascend from the feet proximally
- Numbness
- Pain
- Paresthesias
-
Autonomic Dysfunction
- Urinary Incontinence
- Stool Incontinence
- Temperature dysregulation
- Hypertension
- Associated Symptoms
- Back pain at or near the level of Myelitis (variably present)
VI. Labs
- Cerebrospinal fluid (Lumbar Puncture)
- Indicated after structural causes are excluded by neuroimaging
- Cerebrospinal fluid (CSF) is normal in 50% of cases
VII. Imaging
- MRI Spine with gadolinium contrast
- Imaging to include well above the level of involvement
- May require combined spine MRIs (e.g. cervico-thoracic MRI or thoracolumbar MRI)
- Exclude structural compressive causes (e.g. Epidural Abscess, Epidural Hematoma, acute disc Herniation)
- Surgical emergencies if present
- May also demonstrate inflammatory cord changes
- Imaging to include well above the level of involvement
- CT Myelogram
- Alternative if MRI contraindicated
VIII. Differential Diagnosis
- See Acute Motor Weakness Causes
- See Paresthesia Causes
- See Spinal Cord Syndrome
- See Floppy Infant
- Peripheral Neuropathy
- Structural spinal cord disorders
- Spinal Cord Injury
IX. Causes: Myelitis
- See Acute Flaccid Paralysis
- See Acute Flaccid Myelitis
- Precautions
- Do NOT miss Compressive Neuropathy (e.g. Cauda Equina Syndrome) which is curable with early surgical intervention
- Demyelinating Disease (most common cause)
- Acute Disseminated Encephalomyelitis (ADEM)
- Multiple Sclerosis
- Neuromyelitis optica
- Post-Vaccination Myelitis
- Autoimmune or Inflammatory Myelitis
- Ankylosing Spondylitis
- Antiphospholipid Antibody Syndrome
- Behcet Disease
- Celiac Disease
- Graft-vs-host disease
- Mixed Connective Tissue Disease (MCTD)
- Neurosarcoidosis
- Scleroderma
- Sjogren Syndrome
- Systemic Lupus Erythematosus
-
Bacterial Myelitis
- Bartonella Henselae (Cat Scratch Disease)
- Borrelia Burgdorferi (Lyme Disease)
- Brucellosis melitensis (Brucellosis)
- Campylobacter jejuni (e.g. Acute Diarrhea)
- Chlamydia psittaci (Psittacosis)
- Chlamydia pneumoniae (Chlamydia Pneumonia)
- Coxiella Burnetii (Q Fever)
- Legionella pneumonia
- Leptospira (Leptospirosis)
- Mycobacterium tuberculosis
- Orientia Tsutsugamushi (Scrub Typhus)
- Salmonella paratyphi B (Paratyphoid)
- Streptococcus (Group A and B)
- Treponema pallidum (Syphilis)
- Viral Myelitis
- Coxsackievirus (A and B)
- Cytomegalovirus (Mono-Like Illness)
- DengueVirus
- Echoviruses
- Enterovirus (70 and 71)
- Epstein-Barr Virus (Mononucleosis)
- Hepatitis A Virus
- Hepatitis CVirus
- Herpes Simplex Virus Type 2 (Genital Herpes)
- HIV Infection (see HIV related Myelitis)
- Influenza A Virus (includes H1N1)
- Japanese Encephalitis Virus
- MeaslesVirus
- Mumps Virus
- Poliovirus (1, 2, and 3)
- St. Louis EncephalitisVirus
- Varicella Zoster Virus (Chicken Pox, Shingles)
- West Nile Virus
- Parasitic Myelitis
- Acanthamoeba (Granulomatous Amebic Encephalitis)
- Echinococcus Granulosus (Echinococcosis)
- Gnathostoma Angiostrongylus (Eosinophilic Meningitis)
- Paragonimus westermani fluke (Paragonimiasis)
- Schistomosoma (Schistosomiasis)
- Taenia solium (Neurocysticercosis)
- Toxoplasma gondii (Toxoplasmosis)
- Trypanosoma brucei (African trypanosomiasis, African Sleeping Sickness)
- Fungal Myelitis
- Actinomyces (Actinomycosis)
- Aspergillus (Aspergillosis)
- Blastomyces (Blastomycosis)
- Cryptococcus (Cryptococcosis)
- Coccidioides immitis (Coccidioidomycosis, Valley Fever)
- Paraneoplastic Conditions (Antibody mediated)
- Various antibodies (e.g. ANNA-2, GAD65, NMDAR)
X. Management
- Condition specific management
- Consult neurology
- Consider infectious disease Consultation if infectious Myelitis is suspected (12% of cases)
- Corticosteroids may be indicated in some cases
- Compressive neureopathy causes of acute Myelitis are surgical emergencies
- Emergent Consultation with Spine Surgery or neurosurgery
XI. Prognosis
- Moderate to severe residual deficits remain in two thirds of Transverse Myelitis patients
XII. Resources
- Transverse Myelitis Fact Sheet (NINDS)