(Kiosk 4) Delayed Diagnosis of Transverse Myelitis: A Case Report

Case Diagnosis: Longitudinally extensive transverse myelitis of unknown etiology

Case Description or Program Description: A 66 year-old male with history of parotid gland cancer s/p resection was initially admitted with acute onset left paramidline back and flank pain with radiation and paresthesias down left leg associated with significant weakness. Pertinent exam findings were significant left leg proximal and distal weakness, decreased sensation to light touch and decreased left patellar reflex. Labs including an LP were unremarkable for an inflammatory or autoimmune source. Initial head imaging and multiple spine MRIs were unremarkable. Electrodiagnostic studies were notable for possible plexopathy given absent fibular F waves with reduced recruitment, however the study was completed on day 9 after symptoms. Patient was started on high dose steroids and admitted to acute rehabilitation requiring moderate assistance for mobility and ADLs.

Setting: Acute inpatient rehabilitation facility.

Assessment/Results: Patient had MRI of plexus at rehabilitation which was without pathology. His pain improved and was recovering strength in the left leg. Prior to discharge home, patient began to develop spasticity associated with a thoracic sensory level around T9. He had decreased sensation to pinprick on the right leg below this level. This prompted another MRI thoracic spine revealing a T2 left hemicord signal from T6 to T10. Patient was discharged home at a standby assist level with plans for continued workup as an outpatient for idiopathic longitudinally extensive transverse myelitis.

Discussion (relevance): While cases of Transverse Myelitis are known to be variable, we present a case with initially negative MRI imaging, negative autoimmune and infectious workup including AQP4 which could suggest an idiopathic cause. Furthermore, Transverse Myelitis rarely presents in a Brown-Sequard pattern which can make the diagnosis difficult upon initial presentation.

Conclusions: As described above, presentation of Transverse Myelitis can be variable. Serial clinical exams may assist in diagnosis when imaging and lab workup is inconclusive.