Case Diagnosis: Longitudinal Transverse Myelitis
Case Description: A 10 year old girl with past medical history of vitiligo, who developed a viral syndrome secondary to influenza infection, treated with Oseltamivir, on December 2018. Three week later, patient developed headache, neck and back pain, and lower extremity weakness. Symptoms progressed to involve four extremity weakness and respiratory failure. Laboratory results including rheumatologic work up, including cerebrospinal analysis, was essentially unremarkable; no oligoclonal bands identified. Neuroimaging revealed extensive cervical and thoracic myelitis with cord expansion, as well of focus of increased intensity within the medulla. Patient was diagnosed with Longitudinal Transverse Myelitis and treated with high dose steroids, intravenous immunoglobulins (IVIG), and plasmapheresis, as well as intensive rehabilitation, with significant improvement.
Discussions: Initial evaluation in the Pediatric Intensive Care Unit was remarkable for tetraplegia with bulbar preservation. Initial MRI was remarkable for cervical and thoracic myelitis. Lumbar Puncture was remarkable for normal glucose, protein, and white blood cell levels. The IgG synthesis rate and index were normal, no oligoclonal bands identified. In addition, inflammatory markers were normal and work-up for Herpes and Influenza were negative. Regardless, she was treated aggressively with steroids, IVIG, and plasmapheresis. Afterwards, she regained antigravity strength in left hemibody and improved strength in right hemibody. Upon admission to inpatient rehabilitation, continued progress was seen in functional outcomes although patient is yet unable to walk.
Conclusions: This case represents a rare presentation of Longitudinal Tranverse Myelitis in children. In this particular case, the etiology was attributed to the Influenza virus given the viral syndrome 3 weeks prior presentation and negative work-up for rheumatologic and other infectious causes. Longitudinal Transverse Myelitis may be seen in children following a viral syndrome such as Influenza infection. Treatment with steroids, IVIGs, plasmapheresis, and high intensity rehabilitation seems to improve functional outcomes, although full recovery may be variable.