Merck Manual Chapter 182 Acute Transverse Myelitis

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Merck Manual: Section 14, Chapter 182 Spinal Cord Disorders

Acute Transverse Myelitis

A syndrome, not a disease, in which acute inflammation affects

gray and white matter in one or more adjacent thoracic segments.

Often, the cause is unknown, but some cases follow nonspecific

viral infection or vaccination, suggesting an immunologic

cause; others are associated with vasculitis, use of

amphetamines or IV heroin, Lyme disease, syphilis, TB, or

parasitic or fungal agents.

Symptoms and Signs

Usually, ascending weakness and numbness of the feet and legs

and difficulty voiding develop over a few days; they may

progress over several more days to become severe, usually with

global sensorimotor paraplegia below the lesion, urinary

retention, and loss of bowel control. Occasionally, posterior

column functions are spared, at least initially. Local back

pain, headache, and stiff neck may be present. The syndrome

occasionally recurs.

Diagnosis and Treatment

Acute transverse myelitis must be differentiated from Guillain-

Barré syndrome, anterior spinal artery occlusion, and acute

cord compression, particularly that due to an epidural abscess,

hematoma, or tumor. Treatable causes of acute transverse

myelitis that should be considered are acute meningovascular

syphilis, mycoplasmal infections, and multiple sclerosis.

CSF examination may show monocytes and a slightly increased

protein content. MRI can rule out expanding extramedullary

lesions. MRI or myelography may show swelling of the cord and

occasionally a subarachnoid block at the level of the lesion.

If myelography is used, supine and prone visualization is

necessary to rule out a vascular malformation. Blood serologies

are abnormal in rare cases associated with collagen vascular

disease.

Treatment is nonspecific and symptomatic when no apparent cause

is found. Associated conditions, such as vasculitis, should be

treated. Corticosteroids have no proven benefit, except in

myelitis secondary to multiple sclerosis, in which ACTH or

corticosteroids may lead to regression of symptoms.

Nonetheless, prednisone is often given because the immune

system may be involved in idiopathic cases. For most patients,

except for those with viral meningoencephalitis, disability is

considerable. Generally, the more acute the evolution, the

better the prognosis.

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