A 26-year-old Caucasian male presents to the emergency department with a three day history of dull back pain, progressive difficulty in walking, and urinary retention. He had a mild upper respiratory infection one week ago, but he is otherwise healthy. He is not taking any medications and denies drug abuse. His temperature is 36.7 C (98 F), blood pressure is 120/76 mmHg, pulse is 80/min, and respirations are 16/min. Neurologic examination reveals a decreased muscle strength (2/5) bilaterally in the lower extremities, hyporeactive knee and ankle reflexes, and decreased pain sensation up to the umbilical level. Which of the following is the most likely diagnosis of this patient?

Question

A 26-year-old Caucasian male presents to the emergency department with a three day history of dull back pain, progressive difficulty in walking, and urinary retention.  He had a mild upper respiratory infection one week ago, but he is otherwise healthy.  He is not taking any medications and denies drug abuse.  His temperature is 36.7 C (98 F), blood pressure is 120/76 mmHg, pulse is 80/min, and respirations are 16/min.  Neurologic examination reveals a decreased muscle strength (2/5) bilaterally in the lower extremities, hyporeactive knee and ankle reflexes, and decreased pain sensation up to the umbilical level.  Which of the following is the most likely diagnosis of this patient?

Quizplus · Accepted Answer

Explanation: Rapidly progressive weakness of the lower extremities following an upper respiratory infection, accompanied by sensory loss and urinary retention, is characteristic for transverse myelitis. Dull back pain may be present. Neurologic examination initially reveals muscle flaccidity and hyporeflexia, but spasticity and hyperreflexia develop subsequently. In patients presenting with acute transverse myelopathy, other causes (especially compressive lesions) should be ruled out by obtaining a careful history and performing the appropriate imaging procedures. (Choice A)A herniated intervertebral disk is characterized by an abrupt onset of neurologic deficit and may be related to strenuous activity. A straight-leg raising test will be positive. (Choices B and C) Although an epidural abscess or an acute subdural hemorrhage may develop in otherwise healthy individuals, an underlying cause is usually present (e.g., IV drug abuse or treatment with anticoagulants). (Choice D) Spinal cord compression from a metastatic tumor may present acutely, but the history of systemic malignancy is typical. Educational Objective: Rapidly progressive weakness of the lower extremities following an upper respiratory infection, accompanied by sensory loss and urinary retention, is characteristic for transverse myelitis.

A 26-Year-Old Caucasian Male Presents to the Emergency Department with a Three