Title : Subacute transverse myelitis in an adolescent: A 3-month diagnostic journey with therapeutic implications
Abstract:
Background: Acute transverse myelitis (ATM), a rare inflammatory spinal cord disorder, typically presents with rapid-onset motor, sensory, and autonomic dysfunction. While most cases evolve within 48 hours, 10–15% exhibit subacute progression over weeks to months, often leading to misdiagnosis and delayed treatment. Adolescents are particularly vulnerable due to atypical presentations and low clinical suspicion. This case of a 15-year-old male with 3-month progressive myelopathy challenges classical diagnostic timelines and highlights critical management modalities in neuroinflammatory disorders.
Case Presentation: A previously healthy adolescent developed insidious bilateral lower limb weakness, L3-dermatome sensory loss, and neurogenic bladder dysfunction over 12 weeks. Initial mild symptoms (exercise intolerance, urinary hesitancy) were attributed to overexertion until gait instability and recurrent falls prompted evaluation.
Key Findings:
- Neurological Exam: Upper motor neuron signs (hyperreflexia 3+, bilateral Babinski, power 4/5 MRC).
- MRI Spine: Long-segment T2 hyperintensity (T7–T11) without gadolinium enhancement.
- CSF Analysis: Lymphocytic pleocytosis (5 cells/μL, 89% lymphocytes), elevated protein (0.99 g/L), oligoclonal bands.
- Exclusions found: Negative infectious (HSV/VZV PCR), autoimmune (NMO-IgG), and metabolic (B12: 111 pmol/L, corrected to 318 pmol/L) workup.
Interventions: 1. Immunomodulation: IV methylprednisolone (1 g/day ×5 days) with oral tapering.
2. Autonomic Management: Intermittent catheterization for urinary retention (post-void residual >300 mL), complicated by E. coli UTI requiring IV amikacin.
3. Rehabilitation: Intensive physiotherapy (gait training, spasticity control)
Outcomes: Short-term (1 month): Motor improvement (MRC 2-3 to 4-5), independent ambulation with ankle-foot orthoses. Long-term (10 months): Near-complete radiological resolution (MRI), residual mild spasticity. Persistent urinary urgency managed with anticholinergics.
Discussion: This case underscores three pivotal insights:
1.Diagnostic Challenges: Subacute ATM mimics chronic myelopathies and median diagnostic delay is 11 weeks in adolescents.
2.Therapeutic Response: Steroids remain effective even with delayed initiation, though autonomic complications plays a negative role in prognosis.
3.Multidisciplinary Imperative: 62% of ATM patients require coordinated neurology, urology, and rehab care (J Child Neurol 2023).
Conclusion: Subacute ATM warrants consideration in any progressive adolescent myelopathy. Early immunomodulation and aggressive autonomic management improve outcomes. I root for :
- Revised diagnostic criteria incorporating subacute presentations.
- Standardized rehab protocols to address long-term disability.
- Increased monitoring and alertness for bladder dysfunction as a solid red flag.
Keywords: Subacute transverse myelitis, pediatric neuroinflammation, diagnostic delay, neurogenic bladder, multidisciplinary management
