Modern Look at Transverse Myelitis and Inflammatory Myelopathy: Epidemiology of the National Veterans Health Administration Population

Neuroepidemiology of transverse myelitis and its etiologies in Latin America: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Transverse myelitis (TM) is a rare neuro-inflammatory condition of the spinal cord that can cause chronic and debilitating symptoms reducing quality of life. TM is understudied in developing regions worldwide, particularly in Latin America and the Caribbean (LAC), where the prevalence of TM is unknown. Etiologies of TM are variable, but certain infectious, autoimmune or nutritional abnormalities may be more common in LAC with differing estimated prevalences of these etiologies. Given the paucity of data available on TM in LAC, we conducted a systematic review of the literature and meta-analysis to estimate the prevalence of TM and its etiologies in LAC.

METHODS

We conducted a comprehensive literature search in English, Spanish and Portuguese language databases for TM studies in LAC that included at least ≥ 5 cases of TM, published after 2010. We extracted data on TM frequency, etiologies, and diagnostic tools utilized for the diagnosis from each included article. A meta-analysis was conducted to estimate the proportion of TM and various TM etiologies across articles.

RESULTS

No studies were found that reported the prevalence of TM in LAC or in an individual country. A total of 99 studies were included, with autoimmune (MS, NMO/NMOSD) and infectious etiologies (HTLV-1, arboviruses) most reported. Brazil (53 studies) had the most studies on TM, followed by Mexico (16) and Argentina (15). A total of 26,992 people were included in the meta-analysis, from which the estimated proportion of TM in LAC based on all included studies was 0.47 (95%CI 0.39-0.56) using a random effects model. The utility of MRI spine, lumbar puncture, and disease-specific serological/CSF markers together to diagnose TM was utilized in only 18% of studies.

DISCUSSION

This review highlights important gaps in identifying the community prevalence of TM in LAC with no articles examining the disease's specific frequency. By understanding the epidemiology of TM, its associated etiologies, and barriers to its diagnosis in LAC, there is potential to improve treatment access and disability outcomes for those in the region affected by the disease.

Retrospective, descriptive study of acute myelitis in French Guyana

BACKGROUND

Acute myelitis is a neurological entity, often posing the problem of etiology. The two main causes are infectious or autoimmune. French Guyana is a region of the world where infectious etiologies are multiple, in particular human immunodeficiency virus infection, and autoimmune diseases appear to be emerging. The aim of our study was firstly to determine the proportion of each etiology of acute myelitis in French Guyana, and secondly to describe the clinical, paraclinical and epidemiological characteristics of autoimmune myelitis in French Guyana, with particular reference to neuromyelitis optica spectrum disorder (NMOSD).

METHODS

This retrospective, observational study included all patients who presented with acute myelitis between January 2015 and August 2023 at Cayenne Hospital Center. Each patient's chart was reviewed and patients were classified according to etiology. Demographic and clinical data were collected, as well as blood, lumbar puncture, and cerebral and spinal cord magnetic resonance imaging results.

RESULTS

Of the 40 patients included, immune etiology was found in 74%, including 49% with NMOSD (37% with positive anti-aquaporin-4 antibodies) compared with three patients with infectious etiology. There was no statistically significant difference in complementary examinations between immune and infectious etiologies. The prevalence of NMOSD in French Guyana was estimated at 8/100,000 (6/100,000 for patients with positive anti-aquaporin-4 antibodies). No significant difference in the geographic distribution of patients with NMOSD in French Guyana was demonstrated.

CONCLUSIONS

Our results show a high proportion of autoimmune etiology of acute myelitis in French Guyana, and more particularly of NMOSD. There is a high prevalence of NMOSD, the second highest in the world after the French West Indies. Given this high proportion of autoimmune myelitis, several hypotheses can be put forward, with genetic and environmental factors in the foreground. For patients with acute myelitis in French Guyana, an immune cause is the most likely. It is therefore important to think about this and look for NMOSD in particular, without ignoring an infectious etiology.

Etiological and clinical characterization of longitudinally extensive spinal cord lesions: A 12-year tertiary center experience

INTRODUCTION

Longitudinally extensive spinal cord lesions (LESCL) are characterized by T2-hyperintense signals spanning at least three vertebral body segments, with neuromyelitis optica spectrum disorders (NMOSD) being a significant cause. This study aimed to characterize the clinical, radiological, serological, and cerebrospinal fluid (CSF) features of LESCL and to compare NMOSD and non-NMOSD cases.

METHODS

We conducted a retrospective cross-sectional study of adult patients diagnosed with LESCL at our center over a twelve-year period collecting data on demographics, clinical presentations, MRI findings, CSF analysis, and serological testing for AQP4-IgG and MOG-IgG antibodies. Etiologies were reviewed based on current diagnostic criteria, with comparisons made between NMOSD and non-NMOSD LESCL.

RESULTS

We identified 41 LESCL cases, with NMOSD as the most common etiology (29.3 %) followed by ischemia (14.6 %) and multiple sclerosis (9.8 %). The median length of lesions was seven vertebral segments. Pleocytosis was present in 48.6 % of CSF analyses, with oligoclonal bands found in 10 cases. AQP4-IgG antibodies were positive in 11 of 12 NMOSD patients. NMOSD patients were more likely to be female (p = p.006), and exhibit severe symptoms, such as quadriparesis (p = 0.03) and a cervical sensory level (p = 0.04). MRI findings showed a preference for cervical lesions in NMOSD (p = 0.001) and thoracic lesions in non-NMOSD LESCL (p = 0.007).

CONCLUSIONS

LESCL exhibit considerable clinical diversity, with NMOSD being the predominant etiology. Characteristics such as female sex and cervical MRI involvement may indicate a higher likelihood of NMOSD, while cases in males with thoracic segment involvement may suggest non-NMSOD etiologies such as ischemia.

Emergent Management of Central Nervous System Demyelinating Disorders

OBJECTIVE

This article reviews the various conditions that can present with acute and severe central nervous system demyelination, the broad differential diagnosis of these conditions, the most appropriate diagnostic workup, and the acute treatment regimens to be administered to help achieve the best possible patient outcomes.

LATEST DEVELOPMENTS

The discovery of anti-aquaporin 4 (AQP4) antibodies and anti-myelin oligodendrocyte glycoprotein (MOG) antibodies in the past two decades has revolutionized our understanding of acute demyelinating disorders, their evaluation, and their management.

ESSENTIAL POINTS

Demyelinating disorders comprise a large category of neurologic disorders seen by practicing neurologists. In the majority of cases, patients with these conditions do not require care in an intensive care unit. However, certain disorders may cause severe demyelination that necessitates intensive care unit admission because of numerous simultaneous multifocal lesions, tumefactive lesions, or lesions in certain brain locations that lead to acute severe neurologic dysfunction. Intensive care may be necessary for the management and prevention of complications for patients who have severely altered mental status, rapidly progressive neurologic worsening, elevated intracranial pressure, severe cerebral edema, status epilepticus, or respiratory failure.

It Looks Like a Spinal Cord Tumor but It Is Not

Differentiating neoplastic from non-neoplastic spinal cord pathologies may be challenging due to overlapping clinical and radiological features. Spinal cord tumors, which comprise only 2-4% of central nervous system tumors, are rarer than non-tumoral myelopathies of inflammatory, vascular, or infectious origins. The risk of neurological deterioration and the high rate of false negatives or misdiagnoses associated with spinal cord biopsies require a cautious approach. Facing a spinal cord lesion, prioritizing more common non-surgical myelopathies in differential diagnoses is essential. A comprehensive radiological diagnostic approach is mandatory to identify spinal cord tumor mimics. The diagnostic process involves a multi-step approach: detecting lesions primarily using MRI techniques, precise localization of lesions, assessing lesion signal intensity characteristics, and searching for potentially associated anomalies at spinal cord and cerebral MRI. This review aims to delineate the radiological diagnostic approach for spinal cord lesions that may mimic tumors and briefly highlight the primary pathologies behind these lesions.

Transverse Myelitis in the Setting of Enterobius vermicularis (Pinworm) Infection: Case Report

Myelitis is a rare inflammatory myelopathy, and known associated etiologies only account for a small number of causes. A significant percentage of cases have an unknown etiology and are considered idiopathic. With 64% to 68% of cases fitting into the idiopathic category, helminth infections, and specifically pinworm parainfections, should be considered in cases that would otherwise be classified as idiopathic. This case report outlines a pediatric patient diagnosed with myelitis given her progressive weakness, fussiness, refusal to bear weight as well as magnetic resonance imaging (MRI) demonstrating T2-hyperintense signal and/or T1 gadolinium enhancement, and/or positive cerebrospinal fluid (CSF) inflammatory markers. This patient had a negative evaluation for typical known etiologies for myelitis including no signs of multiple sclerosis and neuromyelitis optica spectrum disorder on brain MRI, oligoclonal banding and aquaporin-4 autoantibodies, and no evidence of bacterial or viral meningitis given normal cell counts and cultures in CSF. She was found to have a pinworm infection, suggesting a parasitic parainfectious etiology of her myelitis. This case outlines the first case noting the correlation between myelitis and pinworm infection in a pediatric patient.

Influence of ganglioside combined with methylprednisolone sodium succinate on efficacy and neurological function in patients with acute myelitis

BACKGROUND

Acute myelitis (AM) can lead to sudden sensory, motor and autonomic nervous dysfunction, which negatively affects their daily activities and quality of life, so it is necessary to explore optimization from a therapeutic perspective to curb the progression of the disease.

AIM

To investigate the effect of ganglioside (GM) combined with methylprednisolone sodium succinate (MPSS) on the curative effect and neurological function of patients with AM.

METHODS

First, we selected 108 AM patients visited between September 2019 and September 2022 and grouped them based on treatment modality, with 52 patients receiving gamma globulin (GG) + MPSS and 56 patients receiving GM + MPSS, assigned to the control group (Con) and observation group (Obs), respectively. The therapeutic effect, neurological function (sensory and motor function scores), adverse events (AEs), recovery (time to sphincter function recovery, time to limb muscle strength recovery above grade 2, and time to ambulation), inflammatory factors (IFs) [interleukin (IL)-6, C-reactive protein (CRP), and tumor necrosis factor (TNF)-α] and other data of the two groups were collected for evaluation and comparison.

RESULTS

The Obs had: (1) A significantly higher response rate of treatment than the Con; (2) Higher scores of sensory and motor functions after treatment that were higher than the baseline (before treatment) and higher than the Con levels; (3) Lower incidence rates of skin rash, gastrointestinal discomfort, dyslipidemia, osteoporosis and other AEs; (4) Faster posttreatment recovery of sphincter function, limb muscle strength and ambulation; and (5) Markedly lower posttreatment IL-6, CRP and TNF-α levels than the baseline and the Con levels.

CONCLUSION

From the above, it can be seen that GM + MPSS is highly effective in treating AM, with a favorable safety profile comparable to that of GG + MPSS. It can significantly improve patients’ neurological function, speed up their recovery and inhibit serum IFs.

Severe mononeuritis multiplex as a rare case of neuro leptospirosis: A case report

Leptospirosis is a zoonotic bacterial disease caused by infection of spirochetes of the genus Leptospira. While typically self-limiting and non-fatal, severe manifestations can arise, including various neurological complications that are often overlooked. This case study presents a 59-year-old man with serologically positive Leptospirosis, who subsequently developed asymmetrical progressive leg weakness, severe back pain, and overflow incontinence suggestive of mononeuritis multiplex. Doxycycline treatment was started and intended to last for seven days. The patient had ongoing paraparesis, but all other problems were disappeared. The present case emphasizes the significance of identifying and treating neurological problems brought on by leptospirosis. To improve suitable treatment plans and patient outcomes, more research on these problems is necessary.

Neurological Considerations with COVID-19 Vaccinations

The benefits of coronavirus disease 2019 (COVID-19) vaccination significantly outweigh its risks on a public health scale, and vaccination has been crucial in controlling the spread of SARS-CoV-2. Nonetheless, several reports of adverse events following vaccination have been published.To summarize reports to date and assess the extent and quality of evidence regarding possible serious adverse neurological events following COVID-19 vaccination, focusing on Food and Drug Administration (FDA)-approved vaccines in the United States (BNT162b2, mRNA-1273, and Ad26.COV2.S).A review of literature from five major electronic databases (PubMed, Medline, Embase, Cochrane Library, and Google Scholar) was conducted between December 1, 2020 and June 5, 2022. Articles included in the review were systematic reviews and meta-analysis, cohort studies, retrospective studies, case-control studies, case series, and reports. Editorials, letters, and animal studies were excluded, since these studies did not include quantitative data regarding adverse side effects of vaccination in human subjects.Of 149 total articles and 97 (65%) were case reports or case series. Three phase 3 trials initially conducted for BNT162b2, MRNA-1273, and Ad26.COV2.S were included in the analysis.The amount and quality of evidence for possible neurological adverse events in the context of FDA-approved COVID-19 vaccinations is overall low tier. The current body of evidence continues to suggest that COVID-19 vaccinations have a high neurological safety profile; however, the risks and benefits of vaccination must continue to be closely monitored.

Identification of specific causes of myelopathy in a large cohort of patients initially diagnosed with transverse myelitis

BACKGROUND AND OBJECTIVES

Identifying the etiologic diagnosis in patients presenting with myelopathy is essential in order to guide appropriate treatment and follow-up. We set out to examine the etiologic diagnosis after comprehensive clinical evaluation and diagnostic work-up in a large cohort of patients referred to our specialized myelopathy clinic, and to explore the demographic profiles and symptomatic evolution of specific etiologic diagnoses.

METHODS

In this retrospective study of patients referred to the Johns Hopkins Myelitis and Myelopathy Center between 2006 and 2021 for evaluation of "transverse myelitis", the final etiologic diagnosis determined after comprehensive evaluation in each patient was reviewed and validated. Demographic characteristics and temporal profile of symptom evolution were recorded.

RESULTS

Of 1193 included patients, 772 (65%) were determined to have an inflammatory myelopathy and 421 (35%) were determined to have a non-inflammatory myelopathy. Multiple sclerosis/clinically isolated syndrome (n = 221, 29%) and idiopathic myelitis (n = 149, 19%) were the most frequent inflammatory diagnoses, while spinal cord infarction (n = 197, 47%) and structural causes of myelopathy (n = 108, 26%) were the most frequent non-inflammatory diagnoses. Compared to patients with inflammatory myelopathies, patients with non-inflammatory myelopathies were more likely to be older, male and experience chronic symptom evolution (p < 0.001 for all). Hyperacute symptom evolution was most frequent in patients with spinal cord infarction (74%), while chronic symptom evolution was most frequent in patients with structural causes of myelopathy (81%), arteriovenous fistula or arteriovenous malformation (81%), myelopathy associated with rheumatologic disorder (71%), and sarcoidosis-associated myelopathy (61%).

CONCLUSIONS

Patients initially diagnosed with "transverse myelitis" are eventually found to have a more specific inflammatory or even non-inflammatory cause, potentially resulting in inappropriate treatment and follow-up. Demographic characteristics and temporal profile of symptom evolution may help inform a differential diagnosis in these patients. Etiological diagnosis of myelopathies would provide better therapeutic decisions.