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Garg D, Radhakrishnan DM, Agrawal U, Vanjare HA, Gandham EJ, Manesh A. Tuberculosis of the Spinal Cord. Ann Indian Acad Neurol 2023; 26:112-126. [PMID: 37179681 PMCID: PMC10171010 DOI: 10.4103/aian.aian_578_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/21/2022] [Accepted: 09/30/2022] [Indexed: 11/18/2022] Open
Abstract
Tuberculosis involving the spinal cord is associated with high mortality and disabling long-term sequelae. Although tuberculous radiculomyelitis is the most frequent complication, pleomorphic clinical manifestations exist. Diagnosis can be challenging among patients with isolated spinal cord tuberculosis due to diverse clinical and radiological presentations. The principles of management of tuberculosis of the spinal cord are primarily derived from, and dependent upon, trials on tuberculous meningitis (TBM). Although facilitating mycobacterial killing and controlling host inflammatory response within the nervous system remain the primary objectives, several unique features require attention. The paradoxical worsening is more frequent, often with devastating outcomes. The role of anti-inflammatory agents such as steroids in adhesive tuberculous radiculomyelitis remains unclear. Surgical interventions may benefit a small proportion of patients with spinal cord tuberculosis. Currently, the evidence base in the management of spinal cord tuberculosis is limited to uncontrolled small-scale data. Despite the gargantuan burden of tuberculosis, particularly in lower and middle-income countries, large-scale cohesive data are surprisingly sparse. In this review, we highlight the varied clinical and radiological presentations, performance of various diagnostic modalities, summarize data on the efficacy of treatment options, and propose a way forward to improve outcomes in these patients.
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Affiliation(s)
- Divyani Garg
- Department of Neurology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | | | - Umang Agrawal
- Department of Infectious Diseases, PD Hinduja Hospital and MRC, Mumbai, Maharashtra, India
| | | | | | - Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
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Park M, Gupta RK. Central Nervous System Mycobacterium Infection. Neuroimaging Clin N Am 2023; 33:105-124. [DOI: 10.1016/j.nic.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Munera M, Buendía E, Sanchez A, Viasus D, Sanchez J. AQP4 as a vintage autoantigen: what do we know till now? Heliyon 2022; 8:e12132. [PMID: 36506380 PMCID: PMC9730132 DOI: 10.1016/j.heliyon.2022.e12132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/09/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Affiliation(s)
- M. Munera
- Medical Research Group (GINUMED), Universitary Corporation Rafael Nuñez, Colombia,Corresponding author.
| | - E. Buendía
- Faculty of Medicine, University of Cartagena, Cartagena, Colombia,Department of Internal Medicine, Centro Hospitalario Serena del Mar, Cartagena, Colombia,Clinical and Biomedical Research Group, Faculty of Medicine, University of Cartagena, Colombia
| | - A. Sanchez
- Faculty of Medicine, University of Cartagena, Cartagena, Colombia,Clinical and Biomedical Research Group, Faculty of Medicine, University of Cartagena, Colombia
| | - D. Viasus
- Division of Health Sciences, Universidad del Norte, Barranquilla, Colombia
| | - J. Sanchez
- Group of Clinical and Experimental Allergy (GACE), IPS Universitaria, University of Antioquia, Medellín, Colombia
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Tang W, Xing W, Li C, Nie Z, Cai M. Differences in CT imaging signs between patients with tuberculosis and those with tuberculosis and concurrent lung cancer. Am J Transl Res 2022; 14:6234-6242. [PMID: 36247264 PMCID: PMC9556475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 07/21/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE The purpose of this study was to compare the differences in imaging features between patients with pulmonary tuberculosis (TB) alone and patients with TB complicated with lung cancer (LCA) as well as to investigate the diagnostic value of CT in these two groups. METHODS In this retrospective study, 110 patients with confirmed TB admitted to the Second Affiliated Hospital of Hainan Medical University from March 2020 to April 2021 were collected and divided into TB+LCA group (50 cases, diagnosed with TB complicated with lung cancer) and TB group (60 cases, diagnosed with TB alone) according to actual diagnosis. The CT results of both groups were analyzed by the same group of physicians in a double-blind manner. The diagnostic value of CT for TB alone and TB complicated with lung cancer was calculated. The differences in CT imaging characteristics between the two groups were investigated. The differences in the structural characteristics of para-cancerous tissue between the two groups were analyzed. RESULTS The diagnostic accuracy of CT was 91.67% in TB patients (55/60) and 92.00% in TB+LCA patients (46/50) without significant difference (X2 =0.004, P=0.949). The detection rate of spiculation, lobulation and cavitation in TB+LCA group was significantly higher than that in TB group (P<0.05), and the distribution, size and wall thickness of cavitation varied significantly between the two groups (P<0.05). Patients in TB group had higher percentage of mediastinal lymph node calcification, peripheral satellite lesion, and mediastinal lymph node enlargement around the TB lesions compared with those in TB+LCA group (P<0.05). CONCLUSION CT has certain application value in differentiating TB alone from TB complicated with lung cancer, and there are many similarities in the imaging features of the two conditions. CT can be considered as a preliminary means of differential diagnosis of TB complicated with lung cancer, which is helpful to the primary screening diagnosis of lung cancer.
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Affiliation(s)
- Wencai Tang
- Department of Radiology, The Second Affiliated Hospital of Hainan Medical University Haikou 570311, Hainan, China
| | - Weijin Xing
- Department of Radiology, The Second Affiliated Hospital of Hainan Medical University Haikou 570311, Hainan, China
| | - Chuanzi Li
- Department of Radiology, The Second Affiliated Hospital of Hainan Medical University Haikou 570311, Hainan, China
| | - Zhongshi Nie
- Department of Radiology, The Second Affiliated Hospital of Hainan Medical University Haikou 570311, Hainan, China
| | - Mubin Cai
- Department of Radiology, The Second Affiliated Hospital of Hainan Medical University Haikou 570311, Hainan, China
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Khan MI, Garg RK, Rizvi I, Malhotra HS, Kumar N, Jain A, Verma R, Sharma PK, Pandey S, Uniyal R, Jain P. Tuberculous myelitis: a prospective follow-up study. Neurol Sci 2022; 43:5615-5624. [PMID: 35739331 PMCID: PMC9225802 DOI: 10.1007/s10072-022-06221-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/15/2022] [Indexed: 11/06/2022]
Abstract
Background Prospective studies regarding tuberculous myelitis are lacking. We aimed to prospectively evaluate patients with tuberculous myelitis to identify the features that distinguish tuberculous myelitis from other myelitis. Methods This was a prospective study. Patients presenting with paraparesis/quadriparesis, and MRI showing myelitis were included. All patients were subjected to clinical, neuroimaging, and laboratory evaluation. Diagnosis of definite tuberculous myelitis was made if GeneXpert test in CSF was positive. Probable tuberculous myelitis was diagnosed if there was evidence of tuberculosis elsewhere in the body. Patients were treated with methylprednisolone and antituberculosis treatment. Patients were followed for 6 months. We compared the clinical, laboratory, and neuroimaging parameters and response to treatment of tuberculous myelitis with other myelitis. P values were adjusted using the Benjamini-Hochberg (BH) procedure to control false discovery rate. Results We enrolled 52 patients. Eighteen (34.6%) patients had tuberculous myelitis. Headache (P = 0.018) was significantly more common in tuberculous myelitis. The CSF protein (P < 0.001), and CSF cell count (P < 0.001) were significantly higher in tuberculous myelitis. On neuroimaging, a LETM was common in tuberculous myelitis. Spinal meningeal enhancement (14; 77.8%), extra-axial collection, and CSF loculation (6; 33.4%), arachnoiditis (3;16.7%), and concomitant spinal tuberculoma (2;11.1%) were other common imaging features of tuberculous myelitis. Tuberculous myelitis patients showed a better response (P = 0.025) to treatment. Conclusion Tuberculous myelitis was seen in approximately 35% of all myelitis cases, in a high tuberculosis endemic zone. Headache, markedly elevated CSF protein and spinal meningeal enhancement were distinguishing features. Tuberculous myelitis patients responded well to corticosteroids.
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Chandrikasing R, Ramnarain S, Bansie R, Yang H, Ponssen H, Ramdhani N. Case report: "an unexpected origin of coma in a young adult". Int J Emerg Med 2021; 14:70. [PMID: 34837945 DOI: 10.1186/s12245-021-00390-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 10/19/2021] [Indexed: 11/10/2022] Open
Abstract
We report a peculiar case of acute non-traumatic coma due to neuromuscular hypoventilation syndrome caused by a non-traumatic spinal cord injury (NTSCI). A 21-year-old patient presented to the emergency room complaining of sudden onset weakness in his lower limbs and shortness of breath. While in the ER, he briefly became comatose and labs revealed an acute respiratory acidosis. Detailed neurologic examination ultimately revealed upper motor neuron signs and quadriplegia. He was ultimately diagnosed with a non-traumatic spinal cord injury, in particular, a cervical transverse myelitis which had caused acute diaphragmatic weakness. Although a very rare cause of coma, emergency medicine physicians need to be aware of transverse myelitis, a disorder that may result in rapidly progressive neurologic decline and is treated with immunomodulation.
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Saied Z, Nabli F, Rachdi A, Jeridi C, Douma B, Belal S, Ben Sassi S. Neuromyelitis optica and concomitant pulmonary tuberculosis: a case report. J Med Case Rep 2021; 15:391. [PMID: 34353370 PMCID: PMC8344150 DOI: 10.1186/s13256-021-03002-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 07/02/2021] [Indexed: 01/02/2023] Open
Abstract
Background Concomitant diagnosis of neuromyelitis optica spectrum disease and pulmonary tuberculosis has rarely been reported.
Case report We report a case involving a young Tunisian male patient who developed dry cough followed, 2 months later, by weakness in the lower limbs. The findings of central nervous system imaging and anti-aquaporin-4 antibody positivity were compatible with the diagnosis of neuromyelitis optica spectrum disease. Constellation of the clinical and the typical radiological pulmonary findings in our patient, coming from an endemic region, allowed the diagnosis of pulmonary tuberculosis, although sputum smear examination for acid-fast bacilli and cultures was negative. The patient received anti-tuberculous polytherapy associated with immunomodulation, consisting of methylprednisolone and intravenous immunoglobulins. Pulmonary infection symptoms initially improved but with no motor recovery. The patient suddenly died at home 4 months after the onset of the first symptoms. Current data regarding the clinical presentation of this underreported concomitant or associated condition, the possible pathophysiological mechanisms, and the therapeutic options were reviewed. Conclusions This case underscores the necessity to understand the exact mechanism of these coincident entities and to clarify the best immunomodulatory choice since immunosuppression targeting neuromyelitis optica spectrum disease can lead to dissemination of pulmonary tuberculosis.
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Affiliation(s)
- Zakaria Saied
- Neurology Department, Mongi Ben Hmida National Institute of Neurology, University of Tunis El Manar, Jbel Lakhdhar Street 1007, LaRabta Bab Saâdoun, Tunis, Tunisia
| | - Fatma Nabli
- Neurology Department, Mongi Ben Hmida National Institute of Neurology, University of Tunis El Manar, Jbel Lakhdhar Street 1007, LaRabta Bab Saâdoun, Tunis, Tunisia
| | - Amine Rachdi
- Neurology Department, Mongi Ben Hmida National Institute of Neurology, University of Tunis El Manar, Jbel Lakhdhar Street 1007, LaRabta Bab Saâdoun, Tunis, Tunisia.
| | - Cyrine Jeridi
- Neurology Department, Mongi Ben Hmida National Institute of Neurology, University of Tunis El Manar, Jbel Lakhdhar Street 1007, LaRabta Bab Saâdoun, Tunis, Tunisia
| | - Bissene Douma
- Neurology Department, Mongi Ben Hmida National Institute of Neurology, University of Tunis El Manar, Jbel Lakhdhar Street 1007, LaRabta Bab Saâdoun, Tunis, Tunisia
| | - Samir Belal
- Neurology Department, Mongi Ben Hmida National Institute of Neurology, University of Tunis El Manar, Jbel Lakhdhar Street 1007, LaRabta Bab Saâdoun, Tunis, Tunisia
| | - Samia Ben Sassi
- Neurology Department, Mongi Ben Hmida National Institute of Neurology, University of Tunis El Manar, Jbel Lakhdhar Street 1007, LaRabta Bab Saâdoun, Tunis, Tunisia
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Abstract
PURPOSE OF REVIEW The patient who presents with an acute spinal cord syndrome with weakness/paralysis of the limbs presents a diagnostic. Two important syndromes are acute transverse myelitis (ATM) and acute flaccid paralysis (AFP). Both can be caused by a number of infectious and noninfectious causes. Since 2014 there have been outbreaks of acute flaccid myelitis (a subgroup of AFP) in the United States, with a national surveillance program underway. In addition, there have been increasing reports of ATM from new and emerging pathogens, and opportunistic infections in immunocompromised hosts. RECENT FINDINGS Infectious causes of ATM or AFP need to be ruled out first. There may be important clues to an infectious cause from epidemiologic risk factors, immune status, international travel, MRI, and laboratory findings. We summarize key features for the more common pathogens in this review. Advances in laboratory testing have improved the diagnostic yield from cerebrospinal fluid, including real-time polymerase chain reaction, metagenomic next-generation sequencing, and advanced antibody detection techniques. These tests still have limitations and require clinical correlation. SUMMARY We present a syndromic approach to infectious myelopathies, focusing on clinical patterns that help narrow the diagnostic possibilities.
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Mohanty NR, Panda B; Faculty of Medicine, SCB Medical College, Cuttack, Odisha, India, Faculty of Medicine, SCB Medical College, Cuttack, Odisha, India. Central Nervous System Tuberculosis Presenting As a Case of Myelitis: A Rare Complication. jcbr 2021; 5:1-4. [DOI: 10.52547/jcbr.5.2.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Anand KA, Bhowmik KK, Sarkar A, Ghosh R, Mandal A, Swaika B, Ray BK. Tubercular longitudinally extensive transverse myelitis (LETM): An enigma for primary care physicians. J Family Med Prim Care 2021; 10:1057-1060. [PMID: 34041124 PMCID: PMC8138341 DOI: 10.4103/jfmpc.jfmpc_2101_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/02/2020] [Accepted: 01/05/2021] [Indexed: 12/15/2022] Open
Abstract
Albeit, all forms of tuberculosis (TB) are endemic in India, spinal intramedullary TB and tubercular longitudinally extensive transverse myelitis (LETM) is deemed extremely rare. With recent advances in the field of neurology, autoimmune astrocytopathy (neuromyelitis optica spectrum disorders, NMOSD), myelin-oligodendrocyte glycoprotein associated encephalomyelitis (MOG-EM), metabolic myelopathy, connective tissue diseases and viral infections have gained considerable focus in the list of differentials of LETM whereas tubercular association is often forgotten. This report presents a rare case of acute transverse myelopathy which unveiled previously undiagnosed pulmonary tuberculosis in an adult rural Indian male. The patient responded well to anti-tubercular therapy and corticosteroids. Exact pathogenesis of LETM in TB remains elusive. Association of TB with MOG-EM has been one of the recent hot-cakes. However, an ill-defined immune-inflammatory response to the infectious agent is the likely cause of tubercular LETM. Hence, the primary care physicians who are the first medical contacts of acute LETM cases and in most cases due to diagnostic dilemma there is an unavoidable delay in accurate diagnosis and initiation of therapy. Primary care doctors should nurture a high index of suspicion to diagnose this potentially lifetime-debilitating yet absolutely treatable clinical condition i.e. tubercular LETM.
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Affiliation(s)
- Kumar Abhishek Anand
- Resident, Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Kalyan Kumar Bhowmik
- Resident, Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Amit Sarkar
- Assistant Professor, Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Ritwik Ghosh
- Resident, Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Arpan Mandal
- Associate Professor, Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Bikash Swaika
- Professor and Head of the Department, Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Biman Kanti Ray
- Professor, Department of Neuromedicine, Bangur Institute of Neurosciences (BIN), Kolkata, West Bengal, India
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Chan SSJ, Kaliya-Perumal AK, Yeo QY, Oh JYL. Transverse myelitis masquerading as cauda equina syndrome, stroke and cervical myelopathy. Biomedicine (Taipei) 2020; 10:45-50. [PMID: 33854913 DOI: 10.37796/2211-8039.1005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 06/18/2019] [Indexed: 11/19/2022] Open
Abstract
Transverse myelitis is an uncommon but well-defined neurological syndrome. However, a high index of suspicion is needed to diagnose this condition, especially when it occurs in concomitance with preexisting spinal canal stenosis. We report our patient, a 48 year old male, who initially presented to our spine clinic with acute onset unilateral lower limb weakness associated with urinary retention, which was suspected to be cauda equina syndrome due to a prolapsed intervertebral disc. However, initial magnetic resonance (MR) imaging showed only mild spinal canal stenosis from L2-L5 and C3– C6 levels; thus, the possibility of cauda equina syndrome was ruled out. A few days later, patient developed ipsilateral upper limb weakness giving an impression of hemiparesis due to stroke. However, imaging of brain returned normal. There was still a dilemma whether symptoms could be due to cervical myelopathy as there was mild cervical cord compression with early myelomalacia changes, but the findings were subtle to come to a definite conclusion. Subsequently, patient desaturated and required ventilatory support. Repeat MR imaging of the cervical spine revealed T2 hyperintensities spanning multiple levels in the cervical cord which highlighted the possibility of transverse myelitis and the diagnosis was clinched after a CSF analysis. Despite the debilitating effects, patient responded well to corticosteroid therapy and gradually recovered. This case is reported to highlight the diagnostic dilemma and the rapid progression of transverse myelitis that demands timely medical intervention to avoid permanent disabilities.
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Abstract
Longitudinally extensive transverse myelitis (LETM) is described in neuromyelitis optica spectrum disorders. Simultaneous active pulmonary tuberculosis in these disorders is a relatively rare phenomenon. We report a 16 year-old boy diagnosed as LETM with clinicoradiological correlation. Further evaluation revealed active pulmonary tuberculosis. He had good recovery following the combination of antituberculosis regimen with corticosteroids.
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Affiliation(s)
- Kiran Kumar Ramineni
- Department of Neurology, Yashoda Super Speciality Hospital, Malakpet, Hyderabad, Telangana, India
| | - Ravi Kanth Jakkani
- Department of Radiology, Yashoda Super Speciality Hospital, Malakpet, Hyderabad, Telangana, India
| | - B V G Swamy
- Department of Pulmonology, Yashoda Super Speciality Hospital, Malakpet, Hyderabad, Telangana, India
| | - Sravan Kumar M
- Department of Radiology, Yashoda Super Speciality Hospital, Malakpet, Hyderabad, Telangana, India
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Md Noh MSF, Bahari N, Abdul Rashid AM. Tuberculous Myelopathy Associated with Longitudinally Extensive Lesion: A Clinicoradiological Review of Reported Cases. J Clin Neurol 2020; 16:369-375. [PMID: 32657056 PMCID: PMC7354966 DOI: 10.3988/jcn.2020.16.3.369] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/18/2019] [Accepted: 12/20/2019] [Indexed: 12/16/2022] Open
Abstract
Acute transverse myelitis is an inflammatory disorder of the spinal cord in which there is no evidence of spinal cord compression. Longitudinally extensive transverse myelitis (LETM) is a specific subtype of acute transverse myelitis that usually affects three or more vertebral levels and produces marked neurological deficits. While the most-common cause of LETM is neuromyelitis optica or neuromyelitis optica spectrum disorder, there are rare cases of other causes mimicking this condition, including tuberculosis (TB). We sought to review the clinicoradiological features of TB myelopathy associated with longitudinally extensive lesion, which may mimic LETM, in the English literature. We searched the PubMed, Google Scholar, Web of Science, and Scopus databases for relevant articles using search terms including “longitudinally extensive transverse myelitis,” “tuberculosis,” “TB spinal cord,” and various combinations of these expressions. Full-text papers were selected without limiting the publication year. We also examined the reference lists of key papers to identify further articles that are potentially relevant. We found 10 cases in 7 papers describing TB myelopathy associated with longitudinally extensive lesion. The demographics, clinical features, relevant cerebrospinal fluid findings, and radiological findings were compiled and summarized. TB myelopathy associated with longitudinally extensive lesion is very rare, with no documented prevalence. Early and accurate diagnosis is important since the condition is potentially treatable.
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Affiliation(s)
- Mohamad Syafeeq Faeez Md Noh
- Senior Registrar and Interventional Neuroradiologist in-training, Department of Imaging, Level 3, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia.
| | - Norafida Bahari
- Consultant Radiologist, Department of Imaging, Level 3, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Anna Misyail Abdul Rashid
- Internal Medicine Physician, Department of Imaging, Level 3, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
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