Current perspectives on the diagnosis and management of acute transverse myelitis

Clinical Approach to Myelopathy Diagnosis

“…The etiologic diagnosis of myelopathies based on categorizing disease mechanisms and etiologies, such as inflammatory and noninflammatory myelopathies, should supersede the transverse myelitis diagnosis widely used in the past several decades. Transverse myelitis , which broadly refers to spinal cord disorders associated with inflammation, is now obsolete because the discovery of the immunologic mechanisms related to specific autoimmune myelitis such as antibodies against glial and neural antigens (eg, anti–aquaporin 4 and anti-MOG antibodies in NMO and MOG-associated disorders, respectively), 12,13 better criteria for diagnosis of demyelinating disorders such as multiple sclerosis, 14 and the use of high-resolution MRI techniques facilitate a more accurate etiologic diagnosis 15,16 . Furthermore, the diagnosis of transverse myelitis has been a source of misdiagnosis and mismanagement of noninflammatory myelopathies, strokes of the spinal cord, spondylotic myelopathies, or myelopathies associated with vitamin B 12 deficiency, which are frequently diagnosed as transverse myelitis 11 and subsequently mistreated with immune-based therapies including immunosuppressive medications.…”

Emergent Management of Central Nervous System Demyelinating Disorders

“…Common symptoms are motor weakness (which can be a mixture of upper motor neuron dysfunction below the level of the lesion and lower motor neuron dysfunction at the level of the lesion), sensory loss with a sensory level, pain in the corresponding dermatomes, sensory ataxia, bowel or bladder dysfunction, erectile dysfunction, autonomic dysfunction, and respiratory failure. Patients with myelitis may need to be admitted to the ICU because of rapidly progressive symptoms, medical complications, or treatment of (or monitoring for) respiratory failure due to large upper cervical cord lesions that affect diaphragmatic function 23-26 . Cervical spinal lesions may also cause autonomic dysfunction, which can be severe in some cases and lead to hemodynamic instability 27,28 …”

“…For all patients on steroids, it is important to (1) monitor serum glucose and initiate insulin, as appropriate; and (2) initiate gastrointestinal prophylaxis with an H2-antagonist or proton pump inhibitor. Moreover, patients receiving prolonged steroids of 20 mg/d or more of oral prednisone (or equivalent alternate corticosteroid) for more than 5 weeks should receive trimethoprim-sulfamethoxazole for prophylaxis against Pneumocystis pneumonia 26 …”

“…Rituximab or cyclophosphamide may be considered as second-line treatments. If there is no known malignancy, evaluation for malignancy by using CT or ideally positron emission tomography (PET)/CT is required because effective management of the underlying malignancy is of utmost importance for controlling the paraneoplastic neurologic syndrome 26 …”

“…Respiratory failure requiring mechanical ventilation may occur as a result of a decreased level of consciousness, orofacial weakness with an inability to protect the airway, and diaphragmatic weakness ( case 9-2 ) 25,26 . Patients may require hemodynamic support for autonomic dysfunction leading to hypo- or hypertension or brady- or tachyarrhythmias.…”