12/11/2018 Acute Transverse Myelitis - Neurologic Disorders - MSD Manual Professional Edition

MSD MANUAL

Professional Version
Professional / Neurologic Disorders / Spinal Cord Disorders

Acute Transverse
Myelitis
By Michael Rubin, MDCM, Professor of Clinical Neurology,
Weill Cornell Medical College; Attending Neurologist and
Director, Neuromuscular Service and EMG Laboratory, New
York Presbyterian Hospital-Cornell Medical Center

Acute transverse myelitis is acute inflammation of gray and white matter in one or more
adjacent spinal cord segments, usually thoracic. Causes include multiple sclerosis,
neuromyelitis optica, infections, autoimmune or postinfectious inflammation, vasculitis, and
certain drugs. Symptoms include bilateral motor, sensory, and sphincter deficits below the
level of the lesion. Diagnosis is usually by MRI, CSF analysis, and blood tests. IV corticosteroids
and plasma exchange may be helpful early. Otherwise, treatment is with supportive measures
and correction of any causes.

(See also Overview of Spinal Cord Disorders.)

Acute transverse myelitis is most commonly due to multiple sclerosis but can occur with
vasculitis, SLE, antiphospholipid syndrome, other autoimmune disorders, SLE,
antiphospholipid syndrome, other autoimmune disorders, mycoplasmal infections, Lyme
disease, syphilis, TB, or viral meningoencephalitis or in patients taking amphetamines, IV
heroin, or antiparasitic or antifungal drugs. Transverse myelitis occurs with optic neuritis in
neuromyelitis optica (Devic disease), once considered a variant of multiple sclerosis but now
considered a distinct disorder.

The mechanism of transverse myelitis is often unknown, but some cases follow viral infection
or vaccination, suggesting an autoimmune reaction. Inflammation tends to involve the spinal
cord diffusely at one or more levels, affecting all spinal cord functions.

Symptoms and Signs

Pain in the neck, back, or head may occur. A bandlike tightness around the chest or abdomen,
weakness, tingling, numbness of the feet and legs, and difficulty voiding develop over hours to
a few days. Deficits may progress over several more days to a complete transverse
sensorimotor myelopathy, causing paraplegia, loss of sensation below the lesion, urinary

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12/11/2018 Acute Transverse Myelitis - Neurologic Disorders - MSD Manual Professional Edition

retention, and fecal incontinence. Occasionally, position and vibration sensation are spared, at
least initially.

The syndrome occasionally recurs in patients with multiple sclerosis, SLE, or antiphospholipid
syndrome.

Diagnosis
MRI and CSF analysis

Other tests to identify treatable causes

Diagnosis of acute transverse myelitis is suggested by transverse sensorimotor myelopathy

with segmental deficits. Guillain-Barré syndrome can be distinguished because it does not
localize to a specific spinal segment.

Diagnosis requires MRI and CSF analysis. MRI typically shows cord swelling if transverse
myelitis is present and can help exclude other treatable causes of spinal cord dysfunction (eg,
spinal cord compression). CSF usually contains monocytes, protein content is slightly
increased, and IgG index is elevated (normal, ≤ 0.85).

A test for a marker for neuromyelitis optica IgG (NMO-IgG)—an autoantibody that targets the
astrocyte water channel protein aquaporin-4—is highly specific and helps distinguish
neuromyelitis optica from multiple sclerosis.

Tests for treatable causes should include chest x-ray; PPD; serologic tests for mycoplasma,
Lyme disease, and HIV; ESR; antinuclear antibodies; and CSF and blood Venereal Disease
Research Laboratory (VDRL) tests. History may suggest a drug as a cause.

The differential diagnosis of acute transverse myelitis includes other transverse myelopathies
due to nutritional deficiencies (eg, deficiency of vitamin B12, folate, zinc, or copper), vascular
insufficiency, and intraspinal tumors.

Brain MRI is done; multiple sclerosis develops in 50% of patients who have multiple
periventricular T2 bright lesions and in 5% who do not have them.

Prognosis
Generally, the more rapid the progression is, the worse the prognosis. Pain suggests more
intense inflammation. About one third of patients recover, one third retain some weakness
and urinary urgency, and one third are bedbound and incontinent.

Multiple sclerosis eventually develops in about 10 to 20% of the patients in whom the cause is
initially unknown.

Treatment

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Treatment of the cause

Sometimes corticosteroids

Treatment of acute transverse myelitis is directed at the cause or associated disorder but is
otherwise supportive.

In idiopathic cases, high-dose corticosteroids are often given and sometimes followed by
plasma exchange because the cause may be autoimmune. Efficacy of such a regimen is
uncertain.

Key Points
Autoimmune and demyelinating disorders, infections, and drugs can inflame tissues in
spinal cord segments, causing transverse myelitis, which may progress to complete
transverse sensorimotor myelopathy.

Do MRI of the spinal cord, CSF analysis, testing for neuromyelitis optica IgG, and other
tests for treatable causes (eg, infections).

Treat the cause if identified, and if no cause is evident, consider corticosteroids and
plasma exchange.

Last full review/revision September 2018 by Michael Rubin, MDCM

© 2018 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA

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