(Kiosk 3) An Interesting Case of Longitudinally Extensive Transverse Myelitis with Marked Recovery

Case Diagnosis: Idiopathic Longitudinally Extensive Transverse Myelitis (LETM)

Case Description: 71-year-old male presented with three weeks of bilateral lower extremity numbness and weakness. Symptoms progressed and significantly impaired ambulation. Exam notable for impaired vibration and proprioception in bilateral lower extremities; brisk patellar reflexes, and up-going toes. Studies notable for T2/STIR hyperintensity from T8-T9 level to Conus Medullaris, acute incidental infarct in the right medulla, and positive ANA and Glutamic Acid Decarboxylase Antibody Assay (GAD-65) in serum. Symptoms stabilized with five days of Solumedrol and Plasmapheresis with an extended Prednisone taper.

Discussion: Transverse myelitis (TM) is characterized by acute or subacute dysfunction of the spinal cord, resulting in impairments below the lesion level. It has an incidence of 1-8 per 1 million people. If it involves three or more segments on sagittal spinal MRI, it is known as LETM whose incidence has not been studied thoroughly. Despite multiple etiologies, the proportion of idiopathic LETM can be up to 60%, and strict criteria by the Transverse Myelitis Consortium Working Group are used to diagnose it. Lastly, GAD65 has been associated with spinal dysfunction at levels significantly higher than in our patient.

Setting: Inpatient Rehabilitation Facility (IRF)

Assessment/Results: On admission to IRF, required minimal to maximal assistance for self-care and transfers and was unable to ambulate. Discharged to a day rehabilitation program at an independent level for self-care and transfers and minimal to moderate assistance for ambulation. After completing day rehabilitation, he was ambulating with a rolling walker and bilateral ankle-foot orthoses. Five months later, he was ambulating without assistive devices and reported improved sensation in his lower extremities.

Conclusion: This case report highlights the importance of a thorough workup for LETM given its rarity and broad differential diagnosis of severe chronic clinical conditions that require specific and timely treatment to avoid serious complications and maximize patient outcomes and recovery.