(P112) Flaccid Paralysis

Chief Complaint : A 70-year-old male presented to the adult emergency department as an EMS pre-notification for altered mental status and hypotension.

History of Present Illness : The patient has a history of with past medical history of hypertension, diabetes, end-stage renal disease on hemodialysis, congestive heart failure, coronary artery disease, cirrhosis status post liver transplant on tacrolimus, C4-C6 laminoplasty. He notes that he was previously found to have cervical stenosis, for which he underwent laminectomy two months prior to presentation; before the surgery, his symptoms were bilateral hand tremors and discoordination. Since then, he endorses progressive bilateral lower extremity weakness for one month and difficulty ambulating for one week. He denies chest pain, back pain, numbness, fever, cough, abdominal pain, dysuria, rash, or any history of intravenous drug use. As per nursing home staff, the patient was in his usual state of health the day prior to arrival. During the emergency department evaluation, the patient suddenly complained of inability to move or feel his legs; he denied any associated chest or back pain.

Pertinent Physical Exam: Upon ED arrival, the patient's vitals were as follows: blood pressure 86/43, heart rate 77, temperature 98 F, respiratory rate 16, pulse oximetry 98% (on room air). On exam, the patient was awake, alert, and answering questions appropriately. Heart sounds were regular and lung sounds were clear. He had full active and passive range of motion of his neck. He was moving bilateral upper extremities without difficulty; bilateral lower extremities strength was 2/5. On reassessment, the patient was found to have bilateral lower extremity flaccid paralysis with no rectal tone.

Pertinent Laboratory Data: Labs: WBC 13
CT cervical spine: grossly normal, orthopedic hardware appears in place
MRI cervical, thoracic, and lumbar spine: mid-thoracic spinal cord swelling and edema concerning for myelitis
CSF: glucose 202, protein 139.2, culture negative

Case Discussion: While initially presenting for altered mental status and hypotension, this patient was found to have focal neurological deficits, prompting emergent neurologic imaging, initiation of broad-spectrum antibiotics and acyclovir, and lumbar puncture. The additional infectious work-up consisted of an echocardiogram negative for vegetations and a lumbar puncture without pathogens. Furthermore, an abdominal aorta ultrasound was done without any concern for aortic dissection. His paraneoplastic work-up was negative. The antibiotics were started to cover for autoimmune causes of myelitis. After treatment, the patient regained a small amount of his bilateral lower extremity strength and sensation.

This patient was found to have transverse myelitis, an inflammation of the spinal cord that can cause motor, sensory, and/or autonomic dysfunction. Although this diagnosis is rare, it is important to be familiar with the etiologies as it will guide management.

There are various causes of transverse myelitis, which include autoimmune, rheumatologic, neoplastic, vascular, and infectious diseases. In our patient with a complex medical history – which includes immunocompromised state, recent spinal surgery, and unstable vitals – it was challenging to determine how best to evaluate and treat him. He was empirically started on antibiotics to cover infectious pathogens, while undergoing evaluation for metabolic, vascular, and paraneoplastic etiologies. When his initial work-up was unrevealing, prior to the results of the MRIs indicative of myelitis, an emphasis was placed on treating an inflammatory cause; thus, he was started on steroids, which served to improve his symptoms.

It is important to note that morbidity depends on the etiology of transverse myelitis. While some patients may recover fully, others have residual deficits, and some remain severely disabled.

References and Acknowledgements (Optional): Asundi A, Cervantes-Arslanian AM, Lin NH, Barbosa F. Infectious Myelitis. Semin Neurol. 2019 Aug;39(4):472-481. doi: 10.1055/s-0039-1688923. Epub 2019 Sep 18. PMID: 31533188.

West TW, Hess C, Cree BA. Acute transverse myelitis: demyelinating, inflammatory, and infectious myelopathies. Semin Neurol. 2012 Apr;32(2):97-113. doi: 10.1055/s-0032-1322586. Epub 2012 Sep 8. PMID: 22961185.

West TW. Transverse myelitis--a review of the presentation, diagnosis, and initial management. Discov Med. 2013 Oct;16(88):167-77. PMID: 24099672.