Acute Demyelinating Transverse Myelitis Secondary to Hepatitis E Infection: A Case Report

Case Diagnosis: A 60-year-old female with acute demyelinating transverse myelitis secondary to hepatitis E infection.

Case Description or Program Description: The patient initially presented to an outside hospital with acute onset back pain, bilateral lower limb weakness, decreased sensation and urinary retention for one day’s time. Upon arrival to the emergency department, the patient underwent CT head which was negative. MRI demonstrated T2 hyper-intensity of the thoracic spinal cord longitudinally extending from T7 to L1, findings that were concerning for acute demyelinating transverse myelitis. She then underwent a spinal angiogram which was negative for vascular malformations, as dural AV fistula could not be excluded. Lumbar puncture demonstrated elevated protein. Liver function testing was within normal limits. She was then treated with 5 days of IV steroids without symptom improvement and discharged to acute inpatient rehabilitation.

Setting: Inpatient Rehabilitation Hospital

Assessment/Results: While in acute rehabilitation, hepatitis panel resulted as hepatitis E IgM negative, IgG positive. She was then started on Ribavirin 400 mg BID for a planned 90-day course.

Discussion (relevance): To our knowledge, there have been few documented cases of transverse myelitis associated with hepatitis E. Typically, hepatitis E is self-limiting, and antivirals are not warranted in the immunocompetent patient. However, there may be significant neurological benefit to treating this patient population with antiviral agents if hepatitis E is found to be the etiology of the transverse myelitis.

Conclusions: Consideration should be given to include a hepatitis E panel in the initial workup of a patient who is suspected to have acute demyelinating transverse myelitis given the potential for neurological recovery after diagnosis and treatment.