Longitudinally extensive transverse myelitis with pulmonary tuberculosis

Abstract

Rationale:Longitudinally extensive transverse myelitis (LETM) is characterized by contiguous inflammatory lesions of spinal cord extending to ≥3 vertebral segments. The etiology of LETM is complicated, including various infection, autoimmune disease, and so on. Neuromyelitis optic spectrum disorder (NMOSD) is the most common cause of LETM. Several case reports have suggested the associations between NMOSD and pulmonary tuberculosis (PTB).Patient concerns:Patient 1, a 20-year-old woman who had a past history of PTB, presented with weakness, numbness, and pain in the limbs. The serum anti-aquaporin-4 antibody (AQP4-Ab) was strongly positive, and the magnetic resonance imaging (MRI) scan of cervical and thoracic spinal cord after admission to the hospital revealed hyperintensity lesions extending from C3 to T8 on T2-weighted (T2W) image, T1-weighted (T1W) image, and fluid-attenuated inversion recovery (FLAIR) image. Patient 2, a 21-year-old woman who had a past medical history of PTB without receiving any treatment, presented for numbness in bilateral lower limbs and in the chest. The anti-AQP4-Ab was negative both in the serum and in the cerebral spinal fluid (CSF) of the patient. The MRI scan during hospitalization of cervical and thoracic spinal cord revealed diffuse hyperintense signal extending C3 to T11 on T2W and FLAIR images and hypointense signal on T1W image.Diagnosis:The first patient was diagnosed with anti-AQP4-Ab positive NMOSD, while the second case was an anti-AQP4-Ab negative LETM patient.Interventions:Both of the patients received a combination of corticosteroid and anti-tuberculosis (isonicotinyl hydrazide 0.3 g/d, rifampin 0.45 g/d, pyrazinamide 1 g/d, and ethambutol 1 g/d) treatment.Outcomes:The patients were followed up for up to 1 year. The Expanded Disability Status Scale (EDSS) of both patients were decreased and the lesion size in the spinal cord was significantly reduced at the time point of the follow-up.Lessons:Combination of anti-tuberculosis and corticosteroid treatment may have better prognosis for patient of LETM with PTB.

Tubercular longitudinally extensive transverse myelitis (LETM)

“…[ 6 7 ] Clinico-radiological differential diagnoses are summarized [see Table 1 ]. [ 5 7 10 11 12 13 14 15 16 17 18 19 20 ] Tubercular LETM is postulated to be a result of an abnormal activation of immune response against cord. [ 21 ] Immune-mediated inflammatory secondary demyelination has been the explanation for NMOSD cases associated with pulmonary TB[ 14 ] but causative association is doubtful.…”

“…[ 9 ] Exact pathogenesis of LETM in TB is yet to be elucidated, however, an immune-inflammatory response to the infectious agent or the infection itself has been postulated as a cause in previous literatures. [ 7 10 ]…”

Tuberculous Myelopathy Associated with Longitudinally Extensive Lesion: A Clinicoradiological Review of Reported Cases

“…Previous reports have considered a combination of steroid and antitubercular therapy to be appropriate. 3 4 18 41 42 43 44 Antiretroviral therapy may be added to the treatment regime for patients with HIV. All of the reported patients analyzed in this review received a combination of steroid and antitubercular therapy, with follow-up clinical and radiological improvements evident in most of the patients.…”

Pulmonary Tuberculosis with Longitudinally Extensive Transverse Myelitis

“…Zhang et al reported similar phenomenon in a young female. 8 Wisniewski Bloom reported demyelination and inflammatory response after injecting BCG into sensitized guinea pigs. 9 Mycobacterium tuberculosis may have common antigens with myelin basic protein.…”