A 26-year-old woman comes to the emergency department due to weakness and numbness in both arms and legs that has progressively worsened over the last 3 days. The patient has no fevers, headache, dizziness, chest pain, shortness of breath, or abdominal pain. She reports no trauma or recent procedures. The patient has no medical conditions and takes no medications. She does not use tobacco, alcohol, or illicit drugs. Temperature is 37 C (98.6 F), blood pressure is 130/82 mm Hg, pulse is 88/min, and respirations are 20/min. On examination, the patient has 4/5 strength in both upper and lower extremities. Sensation is decreased below the neck. MRI shows increased T2 signal in the cervical spinal cord without any mass lesions or compression. Intravenous administration of which of the following is the best next step in management?

Question

A 26-year-old woman comes to the emergency department due to weakness and numbness in both arms and legs that has progressively worsened over the last 3 days.  The patient has no fevers, headache, dizziness, chest pain, shortness of breath, or abdominal pain.  She reports no trauma or recent procedures.  The patient has no medical conditions and takes no medications.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 37 C (98.6 F), blood pressure is 130/82 mm Hg, pulse is 88/min, and respirations are 20/min.  On examination, the patient has 4/5 strength in both upper and lower extremities.  Sensation is decreased below the neck.  MRI shows increased T2 signal in the cervical spinal cord without any mass lesions or compression.  Intravenous administration of which of the following is the best next step in management?

Quizplus · Accepted Answer

11ec25c8_d16a_637a_bc81_7fc36d3fd6a9_MD0003_00 This patient has rapidly progressive, bilateral motor and sensory deficits of the extremities and a distinct sensory level, suggesting myelopathy. With MRI findings of T2 hyperintensity of the spinal cord and no compressive lesion, this presentation is most consistent with transverse myelitis (TM). TM leads to a rapidly progressive myelopathy characterized by weakness, sensory dysfunction, and/or autonomic dysfunction. T2 hyperintensity on spinal MRI is characteristic because the inflammatory infiltrate leads to an increase in water content in the spinal cord. Lumbar puncture often shows evidence of inflammation (eg, lymphocytosis, elevated IgG). spinal MRI Because TM is an immune-mediated disorder, high-dose intravenous glucocorticoids are the first-line management. In addition, plasmapheresis is recommended for patients who have significant motor symptoms or do not respond to glucocorticoids. Most patients partially recover, but persistent deficits are common. (Choices A, B, and C) TM often follows a recent infection (eg, gastroenteritis, upper respiratory infection), and diverse bacteria, fungi, viruses, and even parasites have been implicated. However, a specific pathogen is rarely isolated, and TM is immune mediated (eg, molecular mimicry, super antigen release) rather than due to direct infection. Therefore, antimicrobials are not effective. (Choice D) Intravenous immunoglobulin is used in the treatment of acute inflammatory demyelinating polyneuropathy (ie, Guillain-Barré syndrome). This can present with rapidly progressive, ascending weakness; however, a distinct sensory level would not be present. In addition, spinal MRI is usually normal or shows enhancement of anterior (ie, motor) nerve roots or the cauda equina (vs focal, cervical spinal cord enhancement). Guillain-Barré syndrome Educational objective: Transverse myelitis is an immune-mediated, rapidly progressive myelopathy that typically causes motor and sensory deficits, a distinct sensory level, and focal T2 hyperintensity of the spinal cord on MRI. First-line management is the administration of high-dose intravenous glucocorticoids. References: Guillain-Barré syndrome, transverse myelitis and infectious diseases (http://www.ncbi.nlm.nih.gov/pubmed/29375121)

A 26-Year-Old Woman Comes to the Emergency Department Due to Weakness