AN INTERSTING CASE OF TRANSVERSE MYELITIS

Acute transverse myelitis (ATM), an inflammatory myelitis, is one of the causes of

acute transverse myelopathy. The three main categories in the differential diagnosis of
ATM are demyelination, including multiple sclerosis (MS), neuromyelitis optica (NMO),
and idiopathic transverse myelitis; infections such as herpes zoster and herpes simplex
virus; and other inflammatory disorders such as systemic lupus erythematosus
(SLE)and neurosarcoidosis.
A 20 yr old female who was normal 2 months back gradually developed numbness
sensation over the abdomen 2 months back followed by paraplegia of both lower limbs.
Then after 5 days developed numbness of right upper limb followed by weakness of
right upper limb .This is followed by bladder and bowel disturbances.she has past history
of similar illness in the past . Neurological examination revealed sensory level at C 5
Level . MRI brain and spine showed hyperintensity within spinal cord at C2 to C4 level
and T3 to T7 level with cord edema. CSF analysis showed total count of 120 cells with
normal protein and sugar. CSF culture showed no growth. In view of transverse myelitis ,
5doses of IV steroids given and no improvement seen .So to rule out
Neuromyelitisopitica ANTI-NMO antibodies sent. Visual evoked potential showed
delayed latency in both eyes. ANTI-NMO antibodies specific for neuromyelitisoptica
came positive.Then patient taken for 5 cycles of plasmapheresiswhich showed an
recovery of about 50%. This proved the dramatic response of patients of acute attacts
of Neuro myelitis optica to plasmapheresis .
DEMYLIENATION
SEEN IN T2 FLAIR

DISCUSSION
NMO is an uncommon idiopathic demylinating disease of the CNS producing sequential or simultaneous optic neuritis (ON) and
transverse myelitis (TM). Presence of normal brain MRI, spinal cord involvement of more than three segments and positive antinmo antibodies are points in this case in favour of NMO. Work up for other etiologies for such a presentation including collagen
vascular diseases and infective causes were negative.
Traditionally, the mainstay of management of acute attacks and index events in NMO has been corticosteroids. This patient did
not respond to the usual course of steroids. However, she showed dramatic improvement after plasmapheresis, in both
weakness.
A recent double-blind crossover study of plasmapheresis versus sham exchanges documented that plasmapheresis is beneficial
in treating exacerbations of demyelinating disease that are not responsive to IVMP, especially in cases of NMO.
In another study of steroid unresponsive cases of severe optic neuritis seven out of ten patients showed short term improvement
with plasmapheresis. There is reasonable evidence from the limited studies done so far that plasmapheresis may be an effective
and relatively safe treatment for steroid unresponsive cases of severe CNS demyelination.
This case has been presented to highlight the role of plasmapheresis as a rescue therapy in steroid unresponsive cases of
NMO.Well-controlled multi centric randomized trials need to be undertaken to provide the much needed treatment guidelines for
this disabling condition

References
meickael Bonnan1 and Philippe Cabre2 P lasma Exchange in Severe Attacks of Neuromyelitis Optica Multiple
Sclerosis Internationa 17 November 2011
Amer Awad1,* and Olaf Stve2,3 Idiopathic Transverse Myelitis and Neuromyelitis Optica: Clinical Profiles,pathophysiology
and Therapeutic Choices Current Neuropharmacology, 2011, 9, 417-428
Sundaravadivelu V, Subhuragavelu G, Jaisuresh K, Vinodh Kumar P,Radhika.R Neuromyelitis Optica - Devics Disease - A Case
Report Calicut Medical Journal; 5(3) e5