Acute Transverse Myelitis

Acute Transverse Myelitis, causing spinal cord inflammation, is treated with high-dose intravenous glucocorticoids and plasma exchange for severe cases. Cyclophosphamide may be beneficial, and treatment for secondary TM focuses on the underlying condition. Recurrent TM is managed with immunomodulatory therapies like mycophenolate or rituximab.

2024-01-06 17:06:18 - Editor

Overview of Acute Transverse Myelitis (TM):

Acute transverse myelitis TM is an inflammatory disorder which presents with acute spinal cord dysfunction resulting in weakness, sensory alteration and autonomic impairment (bowel, bladder, and sexual dysfunction) below the level of the lesion. (1)

Etiologies and Associations of TM:

TM usually occurs as a postinfectious complication, but transverse myelitis also exists on a continuum of neuro-inflammatory disorders, including MS, NMOSD, acute disseminated encephalomyelitis, paraneuplastic, SLE and ankylosing spondilitis. (2)

TM and Its Relation to Multiple Sclerosis (MS):

Only 5% of patients presenting with acute TM could develop MS. However, those with partial TMand those with high oligoclonal bands could develop MS at much higher rates. (3)

Initial Treatment of Acute TM:

Treatment of acute TM requires high dose intravenous glucocorticoid ( are methylprednisolone (30 mg/kg up to 1000 mg daily) or dexamethasone (120 to 200 mg daily for adults) for three to five days) to be started as early as possible without the need to wait for the workup to be complete before initiating therapy. (4)

Additional Treatments for Acute TM:

Plasma exchange may be added to steroid for those with motor impairment. Also, patients with TM refractory to steroid, could benefit from plasma exchange. (5)

Plasma Exchange Protocol for TM:

Protocol of plasma exchange is five treatments, each one with exchanges of 1.1- 1.5 plasma volumes, every other day for 10 days. (6)

Use of Cyclophosphamide in TM:

Other treatments include cyclophosphamide (800 to 1200 mg/m2 administered as a single IV dose), could be tried with some benefits as per clinical trials. (7)

Treatment of Acute TM in Various CNS Disorders:

Acute attacks of TM in patients with most types of central nervous system (CNS) inflammatory disorders are typically treated with high dose intravenous glucocorticoids as above. Acute postinfectious TMresponds to Glucocorticoids as above +/- antiviral agents. The treatment of secondary acute TM due to autoimmune etiology or paraneuplastic syndrome is directed to the underlying condition. (8, 9)

Treatment for Recurrent TM:

For patients with recurrent TM, immunomodulatory therapy is a reasonable treatment option with mycophenolate (2 - 3 g daily) or intravenous rituximab (1000 mg every six months). (10, 11)

References

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