Acute Transverse Myelitis in Pregnancy—A Case Report and a Literature Review

Purpose: This case report highlights a rare instance of a 26-week pregnant woman presenting with limb numbness, diagnosed with acute transverse myelitis (ATM) following COVID-19 vaccination. Notably, she tested positive for neuromyelitis optica (NMO) but did not exhibit the typical symptoms of blurred vision. Methods: Data were collected from I Seha in governmental hospitals in Bahrain, providing a comprehensive overview of the patient’s clinical journey. Results: The patient was treated with carbamazepine, steroids, and clexane, leading to the successful delivery of a healthy baby at 34 weeks. However, two years postpartum, she reported new episodes of blurred vision and numbness. Subsequent treatment with Rituximab resulted in significant improvement, with a diagnosis of Devic’s disease established. Conclusion: Acute transverse myelitis is a rare condition, particularly during pregnancy, and in this case, symptoms of Devic’s disease were masked by the absence of blurred vision. This condition predominantly affects females in their 20s during childbearing years and can lead to complications such as premature delivery. Effective management includes steroids and antiepileptic drugs, with clexane playing a crucial role in preventing embolisms. A delivery mode may vary based on obstetric factors, and MRI remains the gold standard for diagnosis. Close follow-up is essential for optimal patient outcomes.

Longitudinally extensive transverse myelitis associated with scrub typhus:A case report

Rationale:Longitudinally extensive transverse myelitis(LETM)is a rare inflammatory demyelinating disease predominantly associated with autoimmune and inflammatory disorders.Scrub typhus can cause a variety of neurological complications,which may result in poor recovery and long-term disability.This report reveals a rare linkage between LETM and scrub typhus.Patient concerns:A 24-year-old female presented with a history of fever for 10 days associated with progressive quadriparesis.Physical examination revealed bilateral lower limb weakness(grade 0/5)and bilateral upper limb weakness(grade 2/5)with reduced sensation below the T3 dermatome.Diagnosis:Scrub typhus presenting with longitudinally extensive transverse myelitis.Interventions:Steroid pulse therapy with antibiotics supported by early intensive rehabilitation.Outcomes:Complete recovery was achieved.Lessons:This case report highlights the importance of considering scrub typhus as a potential cause of LETM in endemic regions,particularly in patients presenting with febrile illness and neurological symptoms.

Influence of ganglioside combined with methylprednisolone sodium succinate on efficacy and neurological function in patients with acute myelitis

BACKGROUND Acute myelitis(AM)can lead to sudden sensory,motor and autonomic nervous dysfunction,which negatively affects their daily activities and quality of life,so it is necessary to explore optimization from a therapeutic perspective to curb the progression of the disease.AIM To investigate the effect of ganglioside(GM)combined with methylprednisolone sodium succinate(MPSS)on the curative effect and neurological function of patients with AM.METHODS First,we selected 108 AM patients visited between September 2019 and September 2022 and grouped them based on treatment modality,with 52 patients receiving gamma globulin(GG)+MPSS and 56 patients receiving GM+MPSS,assigned to the control group(Con)and observation group(Obs),respectively.The therapeutic effect,neurological function(sensory and motor function scores),adverse events(AEs),recovery(time to sphincter function recovery,time to limb muscle strength recovery above grade 2,and time to ambulation),inflammatory factors(IFs)[interleukin(IL)-6,C-reactive protein(CRP),and tumor necrosis factor(TNF)-α]and other data of the two groups were collected for evaluation and comparison.RESULTS The Obs had:(1)A significantly higher response rate of treatment than the Con;(2)Higher scores of sensory and motor functions after treatment that were higher than the baseline(before treatment)and higher than the Con levels;(3)Lower incidence rates of skin rash,gastrointestinal discomfort,dyslipidemia,osteoporosis and other AEs;(4)Faster posttreatment recovery of sphincter function,limb muscle strength and ambulation;and(5)Markedly lower posttreatment IL-6,CRP and TNF-αlevels than the baseline and the Con levels.CONCLUSION From the above,it can be seen that GM+MPSS is highly effective in treating AM,with a favorable safety profile comparable to that of GG+MPSS.It can significantly improve patients’neurological function,speed up their recovery and inhibit serum IFs.

Clinical characteristics, pathogenesis, treatment and prognosis of osteomyelitis in children: a retrospective study from a single center

Osteomyelitis is a common musculoskeletal infection in children,and the acute and chronic osteomyelitis are the two most common type.Acute osteomyelitis affects about 1 in every 5,000 to 10,000 people and is more common in developing countries and economically disadvantaged areas.

Transverse myelitis caused by herpes zoster following COVID-19 vaccination:A case report

BACKGROUND Transverse myelitis(TM)is characterized by sudden lower extremity progressive weakness and sensory impairment,and most patients have a history of advanced viral infection symptoms.A variety of disorders can cause TM in association with viral or nonviral infection,vascular,neoplasia,collagen vascular,and iatrogenic,such as vaccination.Vaccination has become common through the global implementation against coronavirus disease 2019(COVID-19)and reported complications like herpes zoster(HZ)activation has increased.CASE SUMMARY This is a 68-year-old woman who developed multiple pustules and scabs at the T6-T9 dermatome site 1 wk after vaccination with the COVID-19 vaccine(Oxford/AstraZeneca([ChAdOx1S{recombinant}]).The patient had a paraplegia aggravation 3 wk after HZ symptoms started.Spinal magnetic resonance imaging(MRI)showed transverse myelitis at the T6–T9 Level.Treatment was acyclovir with steroids combined with physical therapy.Her neurological function was slowly restored by Day 17.CONCLUSION HZ developed after COVID-19 vaccination,which may lead to more severe complications.Therefore,HZ treatment itself should not be delayed.If neurological complications worsen after appropriate management,an immediate diagnostic procedure,such as magnetic resonance imaging and laboratory tests,will start and should treat the neurological complications.

A Case of Acute Upper Gastrointestinal Bleeding in Liver Cirrhosis Complicated by Acute Cerebral Infarction and Acute Myelitis

Background: Acute upper gastrointestinal bleeding in liver cirrhosis combined with acute cerebral infarction is uncommon in clinical work, and then combined with acute myelitis is even rarer and more complex, which poses a greater challenge to clinical diagnosis and treatment. This paper reports a case of acute upper gastrointestinal bleeding in liver cirrhosis complicated by acute cerebral infarction and acute myelitis, which be hoped to provide a reference for clinical work. Methods: We retrospectively evaluated the clinical information of a 68-year-old female admitted to the Digestive Medical Department with acute gastrointestinal bleeding and appeared limb movement disorder on the third day. Results: The patient was eventually diagnosed with acute upper gastrointestinal bleeding in liver cirrhosis complicated by acute cerebral infarction and acute myelitis. Conclusions: When patients with liver cirrhosis have abnormal neurological symptoms, in addition to liver cirrhosis-related complications, doctors need to consider cerebrovascular diseases and myelitis.

Correlation between serum uric acid levels and clinical characteristics in patients with longitudinally extensive transverse myelitis A case-control study

Uric acid is reduced in demyelinating diseases, including multiple sclerosis and neuromyelitis optica （NMO）. Longitudinally extensive transverse myelitis （LETM） is often an early manifestation of NMO. Whether uric acid levels are reduced at presentation of LETM remains unknown. The present study investigated serum uric acid levels by evaluating 35 patients with LETM, 64 with NMO, 62 with multiple sclerosis, 63 with other neurological diseases and 65 healthy controls. In addition, we tested the correlation between serum uric acid and the clinical characteristics of LETM. All patients were in the acute phase, defined as less than 1 month from onset or relapse. The results revealed that serum uric acid levels in LETM were significantly lower than in multiple sclerosis, other neurological diseases and healthy controls, but no difference was found between LETM and NMO. A negative correlation between uric acid levels and Expanded Disability Status Scale scores was found in LETM patients （r = -0.545, P 〈 0.05）. The results suggest that uric acid levels are reduced in patients with LETM, raising the possibility that lower uric acid levels are an indicator of disease disability. Moreover, reduced uric acid levels may be a risk factor in NMO.

Clinical features of syphilitic myelitis with longitudinally extensive myelopathy on spinal magnetic resonance imaging

BACKGROUND Syphilitic myelitis caused by Treponema pallidum is an extremely rare disease. However, symptomatic neurosyphilis, especially syphilitic myelitis, and its clinical features have been infrequently reported. Only a few cases of syphilitic myelitis have been documented. To the best of our knowledge, there are only 19 reported cases of syphilitic myelitis. However, the clinical features of syphilitic myelitis with longitudinally extensive myelopathy have been still not clear. AIM To explore the clinical features of syphilitic myelitis with longitudinally extensive myelopathy on spinal magnetic resonance imaging (MRI). METHODS First, we report a patient who suffered from syphilitic myelitis with symptoms of sensory disturbance, with longitudinally extensive myelopathy with "flip-flop sign" on spinal MRI. Second, we performed a literature search to identify other reports (reviews, case reports, or case series) from January 1987 to December 2018, using the PubMed and Web of Science databases with the terms including "syphilis","neurosyphilis","syphilitic myelitis","meningomyelitis","central nervous system", and "spine". We also summarized the clinical features of syphilitic myelitis with longitudinally extensive myelopathy. RESULTS A total of 16 articles of 20 cases were identified. Sixteen patients presented with the onset of sensory disturbance (80%), 15 with paraparesis (75%), and 9 with urinary retention (45%). Eleven patients had a high risk behavior (55%). Five patients had concomitant human immunodeficiency virus infection (25%).Serological data showed that 15 patients had positive venereal disease research laboratory test (VDRL)/treponema pallidum particle agglutination (TPHA), and 17 had positive VDRL/TPHA in cerebrospinal fluid (CSF). Seventeen patients were found to have elevated leukocytosis and protein in CSF. On MRI, 16 patients showed abnormal hyperintensities involved the thoracic spine, 6 involved the cervical spine, and 3 involved both the cervical and thoracic spine. There were 3 patients with the "flip-flop sign". All the patients were treated with penicillin, and 15 patients had a good prognosis. CONCLUSION Our case further raises awareness of syphilitic myelitis as an important complication of neurosyphilis due to homosexuality, especially in developing countries such as China.

Rituximab in neuromyelitis optica: A review of literature

Neuromyelitis optica spectrum disorders, or neuromyelitis optica(NMO), is an autoimmune disease of the central nervous system that must be distinguished from multiple sclerosis. Therapeutic approaches to relapse prevention in NMO include immunosuppressants and monoclonal antibodies. Rituximab, a monoclonal antibody that targets CD20 antigen expressed on the surface of pre-B, mature B-lymphocytes and a small subset of T-lymphocytes, has been widely used for the treatment of NMO. In this review, we aim to summarize global experience with rituximab in NMO. We identified 13 observational studies that involved a total of 209 NMO patients treated with rituximab. Majority of rituximab-treated patients evidenced stabilization or improvements in their disability scores compared to pre-treatment period and 66% of patients remained relapse-free during treatment period. Monitoring rituximab treatment response with CD19+ or CD27+ cell counts appears to improve treatment outcomes. We offer clinical pointers on rituximab use for NMO based on the literature and authors' experience, and pose questions that would need to be addressed in future studies.

Varicella-zoster virus-associated meningitis,encephalitis,and myelitis with sporadic skin blisters:A case report

BACKGROUND Varicella-zoster virus(VZV)generally causes chickenpox at first infection in childhood and then establishes latent infection in the dorsal root ganglia of the spinal cord or other nerves.Virus reactivation owing to an impaired immune system causes inflammation along spinal nerves from the affected spinal segment,leading to skin manifestations(herpes zoster).Viremia and subsequent hematogenous transmission and nerve axonal transport of the virus may lead to meningitis,encephalitis,and myelitis.One such case is described in this study.CASE SUMMARY A 64-year-old man presented with dysuria,pyrexia,and progressive disturbance in consciousness.He had signs of meningeal irritation,and cerebrospinal fluid(CSF)analysis revealed marked pleocytosis with mononuclear predominance and a CSF/serum glucose ratio of 0.64.Head magnetic resonance imaging revealed hyperintense areas in the frontal lobes.He had four isolated blisters with papules and halos on his right chest,right lumbar region,and left scapular region.Infected giant cells were detected using the Tzanck test.Degenerated epidermal cells with intranuclear inclusion bodies and ballooning degeneration were present on skin biopsy.Serum VZV antibody titers suggested previous infection,and the CSF tested positive for VZV-DNA.He developed paraplegia,decreased temperature perception in the legs,urinary retention,and fecal incontinence.The patient was diagnosed with meningitis,encephalitis,and myelitis and was treated with acyclovir for 23 days and prednisolone for 14 days.Despite gradual improvement,the urinary retention and gait disturbances persisted as sequelae.CONCLUSION VZV reactivation should be considered in differential diagnoses of patients with sporadic blisters and unexplained central nervous system symptoms.

Concurrent tuberculous transverse myelitis and asymptomatic neurosyphilis:A case report

BACKGROUND Tuberculous myelitis is a rare manifestation of tuberculosis(TB)that is usually caused by hematogenous spread of Mycobacterium tuberculosis(MTB).Neurosyphilis is a neurological disease that occurs when Treponema pallidum invades the brain or the spinal cord.Individually,these two diseases involving the spinal cord are rare and cases of concurrent tuberculous transverse myelitis and asymptomatic neurosyphilis have seldom been reported.CASE SUMMARY A 56-year-old man presented with numbness and pain of both lower limbs for 2 wk and dysuria for 1 wk.Syphilis serology and cerebrospinal fluid(CSF)analysis supported the diagnosis of neurosyphilis and the patient was treated with intravenous ceftriaxone at first,but symptoms still progressed.Then,magnetic resonance images revealed multiple lesions along the cervicothoracic junction,and chest computed tomography showed a typical TB lesion.MTB DNA was detected in the CSF sample by metagenomic next-generation sequencing.Eventually the patient was diagnosed with tuberculous myelitis combined with asymptomatic neurosyphilis.Subsequently,quadruple anti-TB drug standardized therapy was empirically used and his neurological symptoms improved gradually.CONCLUSION Patients can have coinfection with tuberculous transverse myelitis and asymptomatic neurosyphilis.Patients with neurosyphilis should be examined for other pathogens.

Multiple sclerosis and neuromyelitis optica spectrum disorders：some similarities in two distinct diseases

Neuromyelitis optica spectrum disorder（NMOSD）is a chronic inflammatory disorder of the central nervous system that particularly involves the optic nerve and spinal cord.It is pathologically characterized by astrocytopathy,followed by tissue destruction（Fujihara,2011）.Historically,NMOSD has been considered to be an Asian optic-spinal form of multiple sclerosis（MS）,

Transverse myelitis after infection with varicella zoster virus in patient with normal immunity: A case report

BACKGROUND Varicella zoster virus(VZV)is a human neurotropic and double-stranded DNA alpha-herpes virus.Primary infection with VZV usually occurs during childhood,manifesting as chickenpox.Reactivation of latent VZV can lead to various neurological complications,including transverse myelitis(TM);although cases of the latter are very rare,particularly in newly active VZV infection.CASE SUMMARY We report here an unusual case of TM in a middle-aged adult immunocompetent patient that developed concomitant to an active VZV infection.The 46-year-old male presented with painful vesicular eruption on his left chest that had steadily progressed to involvement of his back over a 3-d period.Cerebrospinal fluid testing was denied,but findings from magnetic resonance imaging and collective symptomology indicated TM.He was administered antiviral drugs and corticosteroids immediately but his symptom improvement waxed and waned,necessitating multiple hospital admissions.After about a month of repeated treatments,he was deemed sufficiently improved for hospital discharge to home.CONCLUSION VZV myelitis should be suspected when a patient visits the outpatient pain clinic with herpes zoster showing neurological symptoms.

Cytomegalovirus Transverse Myelitis Secondary to Influenza Infection and Early Recovery:A Case Report

Immunosuppression can lead to opportunistic infections in a host.The evidence of viral infections causing immunosuppression in a host for a transient period is gaining attention.In order to prolong their stay in the human body,viruses affect the human immune systemin various ways.Common viral infections such as influenza can lead to transient lymphocytopenia,which lays the groundwork for more dangerous opportunistic infections.Cytomegalovirus(CMV)infection is a rare cause of inflammatory myelopathy.We present the case of a patient with an influenza infection who progressed to severe acute respiratory distress syndrome,methicillin-resistant Staphylococcus aureus necrotizing pneumonia,and idiopathic lymphocytopenia with a CD4 count of 61 perμL on arrival.After 2 weeks,the patient developed complete flaccid paralysis with sensory and autonomic dysfunction.Because his polymerase chain reaction results of cerebrospinal fluid and blood test were positive for CMV infection,he was treated with high doses of steroids and ganciclovir intravenously.Due to early diagnosis and intervention,the patient was able to recover in 2 months with only minimal residual weakness.Thus,this case stresses on the importance of looking out for opportunistic infections in patients affected by severe viral infections for their early recovery.

Ocular tuberculosis associated with Epstein-Barr virus myelitis: A case report

Ocular tuberculosis(OTB)is a chronic eye infection caused by Mycobacterium tuberculosis.Some cases of myelitis are associated with Epstein-Barr virus(EBV),with 1-5%of EBV infections leading to neurologic complications.We describe a 34-year-old Iranian woman with OTB and EBV coinfection.Despite initial success with anti-TB agents,the disease progressed,necessitating enucleation.Mycobacterium tuberculosis was detected by a tuberculin coagulation test,and EBV was confirmed via polymerase chain reaction.MRI showed plaques in the spinal cord and brain.The patient was treated with anti-TB and antiretroviral agents.Recognizing TB in the differential diagnosis of EBV myelitis is crucial.

Role of autoreactive Tc17 cells in the pathogenesis of experimental autoimmune encephalomyelitis

Background:The pathogenesis of multiple sclerosis(MS)and experimental autoimmune encephalomyelitis(EAE-an animal model of MS)is primarily mediated by T cells.However,recent studies have only focused on interleukin(IL)-17-secreting CD4^(+)T-helper cells,also known as Th17 cells.This study aimed to compare Th17 cells and IL-17-secreting CD8^(+)T-cytotoxic cells(Tc17)in the context of MS/EAE.Methods:Female C57BL/6 mice were immunized with myelin oligodendrocyte glycoprotein peptides 35-55(MOG35-55),pertussis toxin,and complete Freund's adjuvant to establish the EAE animal model.T cells were isolated from the spleen(12-14 days postimmunization).CD4^(+)and CD8^(+)T cells were purified using isolation kit and then differentiated into Th17 and Tc17,respectively,using MOG35-55 and IL-23.The secretion levels of interferon-(IFN-γ)and IL-17 were measured via enzyme-linked immunosorbent assay using cultured CD4^(+)and CD8^(+)T cell supernatants.The pathogenicity of Tc17 and Th17 cells was assessed through adoptive transfer(tEAE),with the clinical course assessed using an EAE score(0-5).Hematoxylin and eosin as well as Luxol fast blue staining were used to examine the spinal cord.Purified CD8^(+)CD3^(+)and CD4^(+)CD3^(+)cells differentiated into Tc17 and Th17 cells,respectively,were stimulated with MOG35-55 peptide for proliferation assays.Results:The results showed that Tc17 cells(15,951±19855VS.55,709±4196cpm;p<0.050)exhibited a weaker response to highest dose(20μg/mL)MOG35-55 than Th17 cells.However,this response was not dependent on Th17 cells.After the 48h stimulation,at the highest dose(20μg/mL)of MOG35-55.Tc17 cells secreted lower levels of IFN-(280.00±15.00vs.556.67±15.28pg/mL,p<0.050)and IL-17(102.67±5.86 pg/mL vs.288.33±12.58 pg/mL;p<0.050)than Th17 cells.Similar patterns were observed for IFN-γsecretion at 96 and 144h.Furthermore,Tc17 cell-induced tEAE mice exhibited similar EAE scores to Th17 cell-induced tEAE mice and also showed similar inflammation and demyelination.Conclusion:The degree of pathogenicity of Tc17 cells in EAE is lower than that of Th17 cells.Future investigation on different immune cells and EAE models is warranted to determine the mechanisms underlying MS.

Human rabies encephalomyelitis in the background of rabies outbreak in animals in Gelephu,Bhutan,2023:a case report

Background Rabies continues to pose significant public health challenges in many developing countries including Bhutan.A probable case of rabies was admitted to our hospital and its reporting led to the uncovering of an outbreak in domestic and wild animals.We discuss the challenges in the diagnosis and management of rabies in a resource-limited setting.Case presentation A 35-year-old male presented with intermittent fever,bilateral lower limb weakness that was rapidly progressive,urinary incontinence with episodes of palpitations and sweating.He had sustained a Category III bite on the right lower thigh with four bite marks,inflicted by a stray dog.He had received post-exposure prophylaxis with intra-dermal anti-rabies vaccine.On initial examination,the patient was in distress but cooperative for the interview.He had pulse rate ranging from 60 to 100/min with episodes of diaphoresis and palpitations,but with normal capillary blood glucose.In the lower limb,the muscle power was zero with absent tendon reflexes in the lower limb and impaired abdominal reflex below T10 level.He had hyperaesthesia below T8,hydrophobia,aerophobia and photophobia.He had multiple spontaneous fasciculations in both the thighs and right deltoid and these later involved the intercostal muscles,neck and face muscles.He had altered sensorium and desaturation for which he required mechanical ventilation.Polymerase chain reaction for rabies virus was negative in cerebrospinal fluid and saliva.Rabies virus neutralizing antibody was negative in cerebrospinal fluid but had high titres in the serum.He received Human Rabies Immunoglobulin after admission.He was managed in the intensive care unit and died 23 days later.After this case was notified,a rapid response team was deployed in the field,and uncovered rabies outbreak in animals in the locality.Conclusions This case called for a serious evaluation of the country’s efforts in achieving zero rabies deaths by 2030.The management of this case identified several critical areas of context-specific interventions in Bhutan.There is also an urgent need to improve diagnostic capabilities at the national reference laboratory and enhance the technical competencies of healthcare workers in the management of dog bite cases.

Epidemiology and clinical characteristics of pediatric osteomyelitis in northern California

Pediatric osteomyelitis is a serious infection in children leading to significant morbidity and hospitalization[1].Infections most commonly occur in the long bones,and 52%-70% are caused by Staphylococcus aureus(S.aureus)[2-4].Methicillin-resistant Staphylococcus aureus(MRSA)has been associated with higher rates of complications for children with acute osteomyelitis.

Guillain–Barré syndrome, transverse myelitis and infectious diseases

Guillain–Barrésyndrome(GBS)and transverse myelitis(TM)both represent immunologically mediated polyneuropathies of major clinical importance.Both are thought to have a genetic predisposition,but as of yet no specific genetic risk loci have been clearly defined.Both are considered autoimmune,but again the etiologies remain enigmatic.Both may be induced via molecular mimicry,particularly from infectious agents and vaccines,but clearly host factor and co-founding host responses will modulate disease susceptibility and natural history.GBS is an acute inflammatory immune-mediated polyradiculoneuropathy characterized by tingling,progressive weakness,autonomic dysfunction,and pain.Immune injury specifically takes place at the myelin sheath and related Schwann-cell components in acute inflammatory demyelinating polyneuropathy,whereas in acute motor axonal neuropathy membranes on the nerve axon(the axolemma)are the primary target for immune-related injury.Outbreaks of GBS have been reported,most frequently related to Campylobacter jejuni infection,however,other agents such as Zika Virus have been strongly associated.Patients with GBS related to infections frequently produce antibodies against human peripheral nerve gangliosides.In contrast,TM is an inflammatory disorder characterized by acute or subacute motor,sensory,and autonomic spinal cord dysfunction.There is interruption of ascending and descending neuroanatomical pathways on the transverse plane of the spinal cord similar to GBS.It has been suggested to be triggered by infectious agents and molecular mimicry.In this review,we will focus on the putative role of infectious agents as triggering factors of GBS and TM.

Incidence and Mortality of Acute Disseminated Encephalomyelitis in China: A Nationwide Population-based Study

Dear Editor,Acute disseminated encephalomyelitis(ADEM)is an immune-mediated demyelinating disorder characterized by a widespread attack of inflammation in the brain and spinal cord that damages myelin[1].ADEM is life-threatening and among the most frequent demyelinating disorders in childhood[2].