Hello, everyone. My name is Michael Arias, and I'm a fourth-year medical student from the Burrell College of Osteopathic Medicine at New Mexico State University, working with Dr. Rishi Shah, a physiatrist at the Baylor College of Medicine. Today, we have an interesting case, transverse myelitis, a rare inflammatory disease usually affecting the spinal cord bilaterally, but here presenting unilaterally. Transverse myelitis, or TM, causes varying degrees of bilateral weakness, sensory deficits, bowel and bladder issues, and autonomic dysfunction. Signs and symptoms can progress from hours to weeks. Importantly, TM is usually seen on both sides. It is diagnosed based on radiographic and clinical findings. Etiology can be idiopathic or associated with a number of diseases, including neuroinflammatory, vascular, or infectious processes, connective tissue disorders, nutritional deficiencies, or even perineoplastic syndromes. And now we present a unique case of idiopathic unilateral myelitis. A 69-year-old Caucasian female presented with acute right-sided paralysis of insidious onset over two to three hours. She also complained of urinary incontinence. Motor exam revealed paralysis of right upper and lower extremities and strength intact in the left upper and lower extremities. No sensory deficits, bowel incontinence, or visual symptoms were reported. Examination of cranial nerves were unremarkable. T2-weighted MRI of the spine showed an area of hyperintensity on the right side from C3 to C5. MRI of the brain showed no acute intracranial events. MRI of the spine is the preferred diagnostic study, and the three most critical criteria for TM are seen here. One, a T2 hyperintense signal change on spinal MRI. Two, no evidence of compressive cord lesion. And three, sensory, motor, or autonomic dysfunction attributable to the spinal cord. CSF analysis revealed increased proteins, no algal clonal bands, and NMO-IgG and MOG-IgG antibodies were both negative. Patient also underwent extensive laboratory work of the West Nile thyroid, vitamins E and B12, MMR, meningitis, and complement 3 and 4, all of which were negative except for C4, which was slightly elevated. TM is usually a diagnosis of exclusion, and so the patient was diagnosed with idiopathic transverse myelitis at this time. Once the diagnosis was determined, the patient was started on a five-day course of IV solumedrol. Afterwards, she began to recover movement in the distal right upper and lower extremities. She was able to make slight movement with fingers and dorsiflexion. These symptoms were ongoing for one week. Once course was completed, patient was transferred to acute patient rehabilitation for functional upgrading. She underwent a comprehensive rehab program with PT, OT, and physiatry to work on gait, mobility, transfers, and ADLs. Upon serial physical exams, patients showed return of dorsiflexion, finger flexion, wrist extension, and supination. In acute inpatient rehab, the patient was monitored by a physiatrist with serial physical exams to test if she would require retreatment or plasmapheresis. Her laboratory data was monitored to optimize functional outcomes. We initiated the patient's rehab program with PT and OT using AFOs. Parallel bars were used initially, followed by rolling walker until discharged with a quad cane. She was treated with functional electrical stimulation as well. Other modalities for mobilization included mirror therapy, seated bicycle, and daily range motion. Upon discharge, patient continued outpatient with both PT and OT and had a three-month follow-up with physiatry. At the follow-up visit three months later, she was able to ambulate at a modified independent level, walking without staff assistance, using a right lower extremity AFO with four-pronged cane. She was independent for all ADLs. Although TM has a strong correlation with developing multiple sclerosis, this patient is yet to be diagnosed with MS. Here are four points of discussion to think about. Systemic conditions such as MS can cause TM. When no cause is identified, such as in this case, patients are diagnosed with idiopathic TM. TM is very rare. About one in eight new cases are diagnosed per million people per year. Of these, 1,400 new cases occur in the U.S., and about 34,000 people have chronic morbidity at any time. There are well-documented consequences if not treated quickly enough, as about 10% of TM patients convert to MS, especially if brain MRI characteristics consistent with MS are present after a first episode of TM. Most patients have at least a partial recovery that begins in one to three months but can proceed over years. 40% of patients experience some degree of persistent disability. In this case, we presented a patient with a unilateral TM, which is a medical emergency. In such potentially disabling conditions, rapid treatment is the goal. Similar cases on PubMed mentioned that unilateral TM is exceedingly rare. There exists a need for more research and understanding of transverse myelitis in order to diagnose correctly and manage rapidly. If the diagnosis of this patient was realized sooner, we could have preserved more function or prevented more weakness in rehab. In conclusion, patients with transverse or unilateral myelitis who develop impaired mobility and dysfunction in ADLs should undergo a comprehensive rehab program with PT, OT, and 24-hour skilled nursing led by a physiatrist. This model can lead to improvement in functional mobility, ADLs, patient safety, transfers, conditioning, and ultimately a safe return to the community. Thank you.

transverse myelitis

inflammatory disease

spinal cord

clinical findings

radiographic findings