Idiopathic Acute Transverse Myelitis


a.k.a. Primary transverse myelitis


Clinical +MRI +laboratory studies
+evidence of inflammation by CSF: pleocytosis or raised IgG index, or by MRI enchancement
+exclude secondary disease: including vascular myelopathy

Clinical features:

Acute or subacute onset
Bilateral symptoms and/or signs, usually symmetric i.e. acute complete transverse myelitis ACTM. [142] Acute partial transverse myelitis APTM may occur i.e. incomplete and asymmetric
Sensory, motor or autonomic deficits due to spinal cord involvement. Progresses to a nadir between 4hr and 21 days.
Transverse refers to anterior and posterior parts of the cord.
Back pain may occur

Findings on Investigations:


  • T2 High signal over many cord segments
  • Diffuse swelling,
  • T1 +contrast: enhancement

Investigations to consider:

MRI +gadolinium brain and spine: assess for MS, neuromyelitis optica, herniated disc, vertebral fracture, metastasis, tumor, abnormal flow voids of AVM
CSF analysis: Cell count +differential, protein, glucose, oligoclonal bands, IgG index
Viral PCR: HSV, etc
CXR: features of sarcoidosis
Blood tests:

  • FBC, basic metabolic panel, LFT
  • ESR, B12, methymalonic acid
  • Vasculitis screen: ESR, CRP, ANA screen, ENA panel (anti- dsDNA, anti-Sm, anti-RNP, SSA, SSB, anti-Jo-1, antitopoisomerase ‘formerly anti Scl-70’, antinucleolar, anticentromere), ANCA (c-ANCA, p-ANCA), Complement C3, C4 and CH50
  • Serology: Mycoplasma pneumoniae (and cold agglutinins), syphilis, HIV-1, HSV,
  • ANA and ENAs
  • ACE levels
  • NMO IgG: to assess for Devic neuromyelitis optica

Lip biopsy: Sjogren syndrome
Tests for Brucella spp. (Brucellosis), Schistosomiasis
14-3-3: early rise is associated with poor outcome.


Methylprednisone 1 gram I.V. 5-7 days followed by steroid taper

  • Plasmapheresis for steroid unresponsive cases
  • Consider empiric therapy for viral or bacterial causes while tests are pending
  • General measures for myelopathy

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