ID
Myelitis
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Myelitis
, Transverse Myelitis, Acute Transverse Myelitis
See Also
Acute Flaccid Paralysis
Acute Flaccid Myelitis
Spinal Cord Syndrome
Cauda Equina Syndrome
Acute Motor Weakness Causes
Paresthesia Causes
Peripheral Neuropathy
Symmetric Peripheral Neuropathy
(
Polyneuropathy
)
Asymmetric Peripheral Neuropathy
(
Mononeuropathy
)
Guillain Barre Syndrome
Cervical Radiculopathy
Lumbar Radiculopathy
Spinal Epidural Abscess
Epidural Hematoma
Cervical Spine Injury
Thoracic Spine Injury
Lumbar Spine Injury
Floppy Infant
Definitions
Myelitis
Spinal Cord Inflammation of various causes including
Viral Infection
s, toxins, autoimmune or vascular conditions
Findings include motor weakness, sensory changes (
Paresthesia
s, 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
Epidemiology
Incidence
(rare): 1.3 to 4.6 per million people
Ages
Most common in children and young adults
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
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
Paresthesia
s
Typically initial sensory symptom
Paresthesia
s ascend from the feet proximally
Numbness
Pain
Autonomic Dysfunction
Urinary Incontinence
Stool Incontinence
Temperature
dysregulation
Hypertension
Associated Symptoms
Back pain at or near the level of Myelitis (variably present)
Labs
Cerebrospinal fluid (
Lumbar Puncture
)
Indicated after structural causes are excluded by neuroimaging
Cerebrospinal fluid (CSF) is normal in 50% of cases
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
Hernia
tion)
Surgical emergencies if present
May also demonstrate inflammatory cord changes
CT Myelogram
Alternative if MRI contraindicated
Differential Diagnosis
See
Acute Motor Weakness Causes
See
Paresthesia Causes
See
Spinal Cord Syndrome
See
Floppy Infant
Peripheral Neuropathy
Symmetric Peripheral Neuropathy
(
Polyneuropathy
, includes
Guillain Barre Syndrome
)
Asymmetric Peripheral Neuropathy
(
Mononeuropathy
)
Botulism
Structural spinal cord disorders
Cervical Radiculopathy
Lumbar Radiculopathy
Cauda Equina Syndrome
Spinal Epidural Abscess
Epidural Hematoma
Spinal Cord Injury
Cervical Spine Injury
Thoracic Spine Injury
Lumbar Spine Injury
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
Bacteria
l 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)
Dengue
Virus
Echoviruses
Enterovirus (70 and 71)
Epstein-Barr Virus
(
Mononucleosis
)
Hepatitis A Virus
Hepatitis C
Virus
Herpes Simplex Virus
Type 2 (
Genital Herpes
)
HIV Infection
(see
HIV related Myelitis
)
Influenza
A
Virus
(includes H1N1)
Japanese Encephalitis Virus
Measles
Virus
Mumps
Virus
Polio
virus (1, 2, and 3)
St. Louis
Encephalitis
Virus
Varicella Zoster Virus
(
Chicken Pox
,
Shingles
)
West Nile Virus
Parasitic Myelitis
Acanthamoeba (
Granuloma
tous Amebic
Encephalitis
)
Echinococcus
Granulosus (
Echinococcosis
)
Gnat
hostoma Angiostrongylus (
Eosinophil
ic
Meningitis
)
Paragonimus westermani fluke (Paragonimiasis)
Schistomosoma (
Schistosomiasis
)
Taenia solium
(
Neurocysticercosis
)
Toxoplasma gondii
(
Toxoplasmosis
)
Trypanosoma brucei (African trypanosomiasis, African
Sleep
ing 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,
NMDA
R)
Management
Condition specific management
Consult neurology
Consider infectious disease
Consultation
if infectious Myelitis is suspected (12% of cases)
Corticosteroid
s may be indicated in some cases
Compressive neureopathy causes of acute Myelitis are surgical emergencies
Emergent
Consultation
with spine surgery or neurosurgery
Prognosis
Moderate to severe residual deficits remain in two thirds of Transverse Myelitis patients
Resources
Transverse Myelitis Fact Sheet (NINDS)
https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Transverse-Myelitis-Fact-Sheet
References
West (2013) Discov Med 16(88):167-77 +PMID: 24099672 [PubMed]
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