3. Hospital course
Mr. A was admitted to the hospital and started on enoxaparin (Lovenox) 40 mg SC daily and dexamethasone (Decadron) 4 mg IV every six hours. He was started on vancomycin 1 mg IV every six hours until the results of the LP. The patient complained of a significant headache, which was thought to be post-lumbar. Fluids and ibuprofen were encouraged. The headache improved by the third day following discharge without further interventions.
Transverse myelitis (TM) is an uncommon neurologic disease that affects the spinal cord through destructive inflammatory responses. The cause is unknown. The inflammation may be a result of humoral immune response, cell-mediated immune response, or complement-mediated immune response. TM can affect any level of the spinal cord, but the destruction occurs in a focal area. Therefore, the patient can determine the definite sensory level of symptoms. TM may even cause some loss of autonomic control (e.g., bowel, bladder, and sexual dysfunction). Precipitating factors may include vaccination or infection as well as vascular, neoplastic, iatrogenic, and autoimmune etiologies. Central nervous system and systemic inflammatory diseases such as MS, systemic lupus erythematosus, and Lyme disease need to be included in the differential diagnosis. Patients will present with back pain as the chief complaint. Because of the inflammation, the excruciating pain may start at the thoracic level and radiate distally in a bandlike sensation around the body at the level of inflammation.
TM is a complex neurologic disorder that is often confused with GBS. Some noted differences between TM and GBS include the following: TM can result in paraparesis or quadriparesis, whereas GBS displays ascending weakness in which the lower extremity is greater than the upper extremity; TM features early loss of bowel and bladder control, whereas GBS is more concerned with autonomic dysfunction of the cardiovascular system; MRI findings for TM show a focal area of T-2 signal, whereas MRI is normal for GBS. CSF shows pleocytosis and, potentially, an increase in immunoglobulin G index, whereas GBS has elevated protein and the absence of pleocytosis.
There is no cure for TM, but early intervention can prevent such permanent disabilities as paraparesis or quadriparesis. Neurological deficits that remain six months out from initial diagnosis are usually irreversible. Mr. A began physical therapy for lower-extremity strengthening prior to discharge until he had a normal gait. He was also started on prednisone 80 mg/day for two days, 60 mg/day for two days, and decreased by 10 mg every two days. Repeat MRI was performed three weeks after discharge. Mr. A was seen in the health services for follow-up and had a complete recovery with no permanent deficits noted on examination.