INTRODUCTION: Transverse Myelitis (TM) is an immune-mediated process which causes neural injury to the spinal cord. We describe a case of a young female who presented with fevers and lower extremity weakness. She was diagnosed to have transverse myelitis and polymerase chain reaction (PCR) of bronchoalveolar lavage fluid was positive for adenovirus.
CASE PRESENTATION: A 30 year old female presented to the emergency room of her local hospital with the complaints of fever and progressive weakness in her legs for three days. She was given a dose of intravenous ceftriaxone and a lumbar puncture was done. The next day she was found unresponsive and required intubation. She was subsequently transferred to the University Hospital.On physical examination at the University hospital she was found to be hemodynamically stable. She was mechanically ventilated, not sedated but unable to follow commands. Her neurological examination revealed positive corneal reflexes, withdrawal to painful stimuli in the left upper extremity and aflexia in all four extremities. Laboratory data showed a white blood cell count of 20.37 with 85% neutrophils, hemoglobin 11.3 grams/deciliter, sodium 128 and sedimentation rate of 42. Lumbar puncture performed at the outside hospital showed a cell count of 65, 96%lymphocytes, glucose 54 and protein 116. Repeat lumbar puncture done at the University Hospital showed similar results. The spinal fluid was negative for Streptococcus pneumoniae, Hemophillus influnzea, Herpes Simplex Virus, cyptococcal antigen and Neisseria meningitidis. The next day she was able to squeeze the examiners hand to command and reflexes were present. Magnetic resonance imaging (MRI) of her brain and cervical cord showed an edematous appearance of the cervical cord with increased T2 signal involving the gray matter of the cervical cord consistent with transverse myelitis. The patient was started on 1 gram solumedrol intravenous daily. A computerized tomography of the chest revealed a tree in bud interstitial pattern in the right lower lobe. A flexible bronchoscopy with bronchoalveolar lavage was negative for bacterial, fungal and viral cultures however PCR testing for adenovirus was positive. Due to minimal improvement in symptoms with two days of high dose steroids, plasmapharesis was initiated. After three daily sessions of plasmapheresis and high dose steroid therapy the patient's neurological status improved considerably. She was extubated on day nine. MRI of the cervical spine done five days after the initial study showed improvement.
DISCUSSIONS: Etiologies of transverse myelitis include systemic inflammatory disorders such as systemic lupus erythematosis and sarcoidosis; demyelinating diseases, including multiple sclerosis; postinfectious or idiopathic transverse myelitis. A review of the literature since 1902 showed that there have only been two other cases of transverse myelitis associated with adenovirus reported [1, 2]. Intravenous steroids are usually the first agents in the treatment. Plasma exchange is initiated if a patient has moderate to severe TM. Our patient received a total of five days of high dose steroid therapy with a slow taper over the next two weeks. She also received five sessions of daily plasma exchange with alternate day sessions every for the next week. By the time of discharge she was walking with assistance of a walker.
CONCLUSION: Transverse myelitis has a number of etiologies including adenovirus as seen in our case. This viral etiology appears to be responsive to corticosteroids and plasma exchange. Resolution of symptoms is possible with this mode of treatment.
DISCLOSURE: Saima Memon, No Financial Disclosure Information; No Product/Research Disclosure Information