1
|
Lim J, Hamouda ES, Fortier MV, Thomas T. Antecedent Minor Trauma and Hyperacute Presentations in Childhood Transverse Myelitis. J Child Neurol 2021; 36:1034-1041. [PMID: 34353149 DOI: 10.1177/08830738211025856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Fibrocartilaginous embolism and spinal cord infarction may resemble transverse myelitis with antecedent minor trauma (sporting activity or minor falls) or with hyperacute (<12-hour) presentation. METHODS Diagnostic criteria for fibrocartilaginous embolism and spinal cord infarction were applied to a 10-year (2007-2016) cohort of children aged 1 month to 16 years with transverse myelitis and clinical, laboratory, neuroimaging, and outcome data compared between those with and without antecedent minor trauma. RESULTS Thirty-two children of median age 8.9 (range 2.7-15.8) years were included; 19 (59%) were female. Falls at home, school, or play (6 children, 60%), swimming (2, 20%), physical education (1, 10%), and caning (1, 10%) were antecedent events in 10 (31%) children. Six (19%) had hyperacute presentations. One patient met spinal cord infarction criteria; none had fibrocartilaginous embolism. Children with transverse myelitis and antecedent minor trauma had single, short spinal cord lesions (median 3 vertebral bodies) but without a specific neuroimaging lesion pattern. None had intervertebral disc abnormalities or brain involvement and were negative for myelin oligodendrocyte and aquaporin 4 antibodies. Twenty-five (86%) of 29 had cerebrospinal fluid inflammation, and 30 (94%) received immunotherapy. Thirty (97%) were followed for a median of 3.6 (0.1-10.2) years, with good outcome (modified Rankin Scale score 0-1) in the majority (80%). Four (75%) with hyperacute presentation had a good outcome (modified Rankin Scale score 0-1), but the patient with spinal cord infarction was the most disabled (modified Rankin Scale score 4). CONCLUSION Minor trauma or hyperacute presentations does not always indicate fibrocartilaginous embolism or spinal cord infarction. Children with minor trauma preceding transverse myelitis have a distinct clinicoradiologic syndrome, with good outcome following immunotherapy.
Collapse
Affiliation(s)
- Jocelyn Lim
- Neurology Service, Department of Paediatric Medicine, 37579KK Women's and Children's Hospital, Singapore
| | - Ehab Shaban Hamouda
- Department of Radiology, Children and Adolescent Services, 200462Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Marielle Valerie Fortier
- Department of Diagnostic & Interventional Imaging, 37579KK Women's and Children's Hospital, Singapore
| | - Terrence Thomas
- Neurology Service, Department of Paediatric Medicine, 37579KK Women's and Children's Hospital, Singapore
| |
Collapse
|
2
|
Celik H, Aksoy E, Oztoprak U, Ceylan N, Aksoy A, Yazici MU, Azapagasi E, Eksioglu AS, Yücel H, Senel S, Yuksel D. Longitudinally extensive transverse myelitis in childhood: Clinical features, treatment approaches, and long-term neurological outcomes. Clin Neurol Neurosurg 2021; 207:106764. [PMID: 34171586 DOI: 10.1016/j.clineuro.2021.106764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
AIM Longitudinally extensive transvers myelitis (LETM) is a rare and disabling condition in childhood. The aim of the present study was to share experiences from our center regarding the treatment features and clinical and radiologic course in our LETM patients in light of the literature data. MATERIAL AND METHOD The study was designed as cross-sectional and included children who followed for LETM at our pediatric neurology clinic between 2010 and 2019. ATM was diagnosed according to the diagnostic criteria report from the Transverse Myelitis Consortium Working Group. LETM was defined as the presence of spinal cord lesions spanning a length of 3 or more consecutive vertebral segments. The patients' medical records were examined in terms of demographic characteristics, presenting symptoms, history of infection prior to and during LETM, prodromal history, neurological examination, laboratory and radiological findings, clinical course, and treatment. The Barthel Index was used to assess the physical independence in activities of daily living of patients with LETM who were followed for at least one year. RESULTS A total of 15 (8 girl) patients were included in the study. The patients were between 1 and 17 years of age. Presenting symptoms included inability to walk in 12 patients, incontinence in 9 patients, low back pain in 4 patients, abdominal pain in 2 patients, and inability to use the arms in 2 patients. In Barthel Index assessment of physical independence in activities of daily living, 8 patients were evaluated as completely independent, 3 patients as moderately dependent, and 2 patients as slightly dependent. When the 4 patients with motor area impairment and moderate dependency according to the Barthel Index were examined, it was noted that all of them had been admitted 4 days after the onset of symptoms and that 2 (13.3%) had cervicothoracic involvement and 2 (13.3%) had involvement of the entire cord. CONCLUSION Shorter delay from symptom onset to initiation of immunomodulatory therapy as well as effective rehabilitation resulted in favorable outcomes, with the most noticeable improvement in the areas of motor function and incontinence.
Collapse
Affiliation(s)
- Halil Celik
- Department of Pediatric Neurology (DY) University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Erhan Aksoy
- Department of Pediatric Neurology (DY) University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Ulkuhan Oztoprak
- Department of Pediatric Neurology (DY) University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Nesrin Ceylan
- Department of Pediatric Neurology (DY) University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Ayse Aksoy
- Department of Pediatric Neurology (DY) University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Mutlu Uysal Yazici
- Department of Pediatric Intensive Care University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Ebru Azapagasi
- Department of Pediatric Intensive Care University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Ayse Secil Eksioglu
- Department of Radiology University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Husniye Yücel
- Department of Pediatrics University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Saliha Senel
- Department of Pediatrics University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Deniz Yuksel
- Department of Pediatric Neurology (DY) University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| |
Collapse
|
3
|
Helfferich J, Bruijstens AL, Wong YYM, Danielle van Pelt E, Boon M, Neuteboom RF. Prognostic factors for relapse and outcome in pediatric acute transverse myelitis. Brain Dev 2021; 43:626-636. [PMID: 33509615 DOI: 10.1016/j.braindev.2020.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/04/2020] [Accepted: 12/24/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE It may be difficult for clinicians to estimate the prognosis of pediatric acute transverse myelitis (ATM). The aim of this study was to define prognostic factors for relapsing disease and poor outcome in pediatric ATM. METHODS This prospective cohort study included 49 children, 18 boys and 31 girls (median age 13.1 years, IQR 6.5-16.2) with a first episode of ATM. Factors associated with relapsing disease and poor outcome (Expanded Disability Status Scale (EDSS) ≥ 4) were assessed during a median follow-up of 37 months (IQR 18-75). RESULTS In total, 14 patients (29%) experienced ≥ 1 relapse(s) and nine patients (18%) had a poor outcome. Factors at onset associated with relapsing disease included higher age (16.1 vs. 11.6 years, p = 0.002), longer time to maximum severity of symptoms (5.5 vs. 3 days, p = 0.01), lower maximum EDSS score (4.0 vs. 6.5, p = 0.003), short lesion on spinal MRI (64 vs. 21%, p = 0.006), abnormalities on brain MRI (93 vs. 44%, p = 0.002) and presence of oligoclonal bands in cerebrospinal fluid (67 vs. 14%, p = 0.004). The only factor associated with poor outcome was presence of a spinal cord lesion on MRI without cervical involvement (56 vs. 14%, p = 0.02). CONCLUSION Pediatric ATM patients presenting with clinical, radiological and laboratory features associated with multiple sclerosis (MS) are at risk for relapsing disease. In absence of these known MS risk factors at onset of disease these patients are at low risk for relapses. Only a minority of pediatric ATM patients in this cohort have a poor outcome.
Collapse
Affiliation(s)
- Jelte Helfferich
- Department of Neurology, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, the Netherlands; Department of Neurology, Erasmus Medical Center, Room Ee-2230, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
| | - Arlette L Bruijstens
- Department of Neurology, Erasmus Medical Center, Room Ee-2230, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
| | - Yu Yi M Wong
- Department of Neurology, Erasmus Medical Center, Room Ee-2230, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
| | - E Danielle van Pelt
- Department of Neurology, Erasmus Medical Center, Room Ee-2230, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
| | - Maartje Boon
- Department of Neurology, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, the Netherlands.
| | - Rinze F Neuteboom
- Department of Neurology, Erasmus Medical Center, Room Ee-2230, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
| | | |
Collapse
|
4
|
Ashfaq MA, Javed I, Arshad M, Yaseen MR. Role of Methyl Prednisolone in Longitudinal Extensive Transverse Myelitis (LETM) in Children. Pak J Med Sci 2020; 36:451-455. [PMID: 32292451 PMCID: PMC7150395 DOI: 10.12669/pjms.36.3.1232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Objective: The role of methyl prednisolone in longitudinal extensive transverse myelitis in children is not completely discovered in developing country like Pakistan. So this is the first study which aimed to evaluate the efficacy of methyl prednisolone in longitudinal extensive transverse myelitis in children. Methods: This is quasi experimental hospital based descriptive prospective study. The data was collected from 34 children admitted in Paediatric Neurology department through Outpatient/emergency department in Children’s Hospital and the Institute of Child Health, Lahore for period of one year from January 2018 to December 2018. The children full filling the inclusion criteria were observed before and after giving injection methyl prednisolone 30mg/kg/dose (maximum dose one Gram irrespective of the body weight) once daily for five days in the form of intravenous infusion. Results: Complete recovery was seen in 41.2% while 58.8% showed partial recovery. The correlation of response to treatment (recovery) with gender, area of spinal cord involvement, muscle power and autonomic dysfunction is found at significance level of five percent according to Chi square test. Conclusion: Early consideration and administration of methyl prednisolone in longitudinally extensive transverse myelitis in children can be beneficial and can help to reduce the morbidity.
Collapse
Affiliation(s)
- Muhammad Azeem Ashfaq
- Dr. Muhammad Azeem Ashfaq, MBBS, FCPS. Senior Registrar, Department of Paediatric Neurology, The Children's Hospital & the Institute of Child Health, Lahore, Pakistan
| | - Iram Javed
- Dr. Iram Javed, MBBS, FCPS. Assistant Professor, Department of Paediatric Neurology, The Children's Hospital Faisalabad, Pakistan
| | - Muhammad Arshad
- Dr. Muhammad Arshad, MBBS, FCPS Associate Professor, Sargodha Medical College, Sargodha, Pakistan
| | - Muhammad Rizwan Yaseen
- Muhammad Rizwan Yaseen, Assistant Professor, Department of Economics, Government College University, Faisalabad, Pakistan
| |
Collapse
|
5
|
|
6
|
Magnetic Resonance Imaging and Clinical Features in Acute and Subacute Myelopathies. Clin Neuroradiol 2017; 27:417-433. [PMID: 28667382 DOI: 10.1007/s00062-017-0604-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 06/07/2017] [Indexed: 12/22/2022]
Abstract
Differential diagnosis of acute and subacute transverse myelopathy includes inflammatory, infectious, vascular, metabolic and paraneoplastic etiologies. Information on the diagnostic approach to transverse myelopathy with regard to daily clinical practice is provided. The differentiation between five lesion patterns on magnetic resonance imaging (MRI) in myelitis may be helpful: (1) longitudinal extensive transverse myelitis, (2) short segment ovoid or peripherally located, (3) "polio-like", (4) granulomatous and (5) segmental with rash. A correlation with these imaging features is supported if the clinical course and neurological symptoms are known. Although the mean interval from onset to nadir of symptoms in spinal cord infarction is 1 h, an overlap with a fulminant course of myelitis is possible, and impaired diffusion may also occur in acute inflammatory processes. As a result, laboratory testing, including aquaporin-4 antibodies and cerebrospinal fluid analysis, is crucial for the correct interpretation of imaging findings. Moreover, the discrimination of acute complete and acute partial transverse myelitis is advantageous in order to identify diverse entities, the latter often being a precursor to multiple sclerosis. Additional brain imaging is mandatory in suspected demyelinating, infectious, neoplastic and systemic autoimmune disease. A symmetrical lesion pattern restricted to individual tracts or dorsal columns indicates subacute combined degeneration of the spinal cord and, in addition to deficiency syndromes, a paraneoplastic etiology should be considered.
Collapse
|
7
|
Suthar R, Sankhyan N, Sahu JK, Khandelwal NK, Singhi S, Singhi P. Acute transverse myelitis in childhood: A single centre experience from North India. Eur J Paediatr Neurol 2016; 20:352-60. [PMID: 26924166 DOI: 10.1016/j.ejpn.2016.01.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 01/12/2016] [Accepted: 01/23/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Acute transvers myelitis (ATM) is a rare and disabling condition in childhood. There are only few reports of clinical profile, prognosis and predictors of ATM from developing countries. OBJECTIVE To study the clinical profile of children with ATM and predictors of its outcome. METHOD Retrospective analysis of children <12 years of age diagnosed with ATM over a period of 6 years from a tertiary care institute. RESULTS Thirty six children (21 boys, median age-7.5 years) were diagnosed with ATM. Weakness was symmetrical at onset in 27 (75%) children with progression over a median of 2 days (IQR 1-5 days). Severe weakness at onset with lower limb power ≤ 1/5 on MRC scale was present in 27 (75%), a sensory level in 25(69.4%) and bladder dysfunction in 31(86.1%) children. MRI showed longitudinal extensive myelitis (LETM) in 27 (75%) children and the thoracic cord was most commonly affected [18 (50%)]. On a median follow up of 35 months (range IQR 11-57 months); 15 (41.7%) were non ambulatory or required assistance to walk. Severe weakness at onset with power ≤ 1 on MRC scale, spinal shock, respiratory muscle weakness, mechanical ventilation, greater mean time to diagnosis and treatment was associated with bad outcome. ATM was a monophasic illness in all, except in 3 children; all with neuromyelitis optica spectrum disorder. Progression to multiple sclerosis was not seen in any child in our cohort. CONCLUSION In this series of childhood ATM from North India, the disease was severe, monophasic and involved long segments (≥ 3) of cord in majority. Nearly half the children remain dependent on follow up. Delayed diagnosis and delayed initiation of steroid therapy was associated with poor outcome.
Collapse
Affiliation(s)
- Renu Suthar
- Unit of Pediatric Neurology and Neurodevelopment, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Naveen Sankhyan
- Unit of Pediatric Neurology and Neurodevelopment, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Jitendra K Sahu
- Unit of Pediatric Neurology and Neurodevelopment, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Niranjan K Khandelwal
- Department of Radio Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Sunit Singhi
- Pediatric Emergency and Intensive Care Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Pratibha Singhi
- Unit of Pediatric Neurology and Neurodevelopment, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
| |
Collapse
|