Extensive Myelitis After Oral Polio Vaccination: Mri Features a B C

JBR–BTR, 2014, 97: 358-360.

Extensive myelitis after oral polio vaccination: MRI features

D. Kozic1, V. Turkulov 2, M. Bjelan1, K. Petrovic3, S. Popovic-Petrovic4, F.M. Vanhoenacker5,6,7

A 7-year-old boy presented with fever and ataxia 20 days after oral polio vaccination. Magnetic resonance imaging showed extensive myelitis, involving both anterior and posterior horns of the gray matter. Complete posttreatment recovery was evident. Postvaccinal myelitis after oral polio vaccination, of either infectious or immune mediated etiology, is very rare entity that should be promptly recognized in order to initiate adequate treatment.

Key-word: Viruses.

The term poliomyelitis derives from Greek words “polios“, meaning gray and “myelos“, meaning marrow, referring to the inflammation of the spinal cord gray matter. The viral invasion affects the motor neurons of the anterior horn cells, responsible for the movement of the limbs, trunk and intercostal muscles. On very rare occasions, the attenuated virus in oral polio vaccine reverts into a form that can cause severe clinical manifestation of poliomyelitis that need to be treated A B promptly (1). Although patients with primary immunodeficiencieshave a much higher risk of the disease, vaccine-associated poliomyelitis or vaccine-induced transverse myelitis may also occur in healthy recipients. Public concerns regarding potential postvaccinal adverse effects in all C D E prophylactic inoculations are pres- Fig. 1. — Enlargement of the spinal cord on T1W sagittal images (A), associated with ent. Replacement of oral vaccine extensive inflammatory process of the spinal cord evident on T2W sagittal images (B), with inactivated poliomyelitis vac- mainly involving the anterior and posterior horns of the gray matter, best appreciated cine is growing (2). The aim of our on T2W axial images in cervical (C) and thoracic level (D) and diffusion-weighted report is to stress the role of imaging images (E). in detecting the potential involvement of the spinal cord, as a conse- quence of oral polio vaccination. brospinal fluid revealed the presence associated with diffusely increased of 30 white blood cells, mostly lym- T2W signal affecting the posterior Case report phocytes, normal glucose and pro- column of the spinal cord white mat- tein levels. The child received oral ter, most consistent with inflamma- A 7-year-old previously healthy polio vaccine 20 days before initial tion and edema (Fig. 1). No enhance- boy, presented with fever (38.5C), symptoms. Cerebellitis was suspect- ment of the lesions was noted after severe neck pain, ataxia, muscle ed and brain magnetic resonance intravenous contrast administration. pain and weakness. Neurological imaging (MRI) was requested. No Diffusion restriction of both anterior examination revealed normal mental abnormalities were found on brain and posterior horns of the gray mat- status and cranial nerves, the MRI. However, cervical spine MRI ter was compatible with either post- presence of increased deep tendon revealed the presence of extensive vaccinal poliomyelitis or vaccine- reflexes and positive Romberg and myelitis, involving both anterior and induced transverse myelitis. No re- Mingazzini signs. Evaluation of cere- posterior horns of the gray matter, stricted diffusion of the spinal cord white matter tracts was evident. Intra venous immunoglobulin and cortico- steroid therapy and oral antibiotics From: 1. Oncology Institute of Vojvodina, Diagnostic Imaging Center, University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia, 2. Clinical Center of Vojvodina, were promptly initiated. General im- Clinic of Infectious diseases, University of Novi Sad, Faculty of Medicine, Novi Sad, provement with gradual regression Serbia, 3. Clinical Center of Vojvodina, Center of Radiology, University of Novi of the neurological signs was evident Sad, Faculty of Medicine, Novi Sad, Serbia, 4. Oncology Institute of Vojvodina, in the following weeks. No residual Rehabilitation Department , University of Novi Sad, Faculty of Medicine, Novi Sad, symptoms and signs were present Serbia, 5. Department of Radiology, AZ Sint-Maarten Duffel-Mechelen, Mechelen, on neurological examination 10 Belgium, 6. Department of Radiology, Antwerp University Hospital, Edegem, Belgium, months later, and follow-up MRI re- 7. University of Ghent, Faculty of Medicine and Health sciences, Ghent, Belgium. vealed no residual abnormalities in Address for correspondence: Prof Dr Dusko Kozic, M.D., Institutski put 4, 21204 Sremska the spinal cord (Fig. 2). Kamenica, Serbia. E-mail: [email protected]

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A B C Fig. 2. — Complete regression of poliomyelitis with normal spinal cord morphologic characteristics on T1W sagittal (A), T2W sagittal (B) and turbo spin-echo T2W axial (C) images.

Discussion amyotrophic lateral sclerosis. Patho- cess caused by attenuated strains of logically, neuronal loss and gliosis vaccinal polio virus, or with immune- Increased T2 signal involving the were extending outside the anterior mediated transverse myelitis. Both anterior horns of the spinal cord gray horns, affecting the intermediate entities are extremely rare. Literature matter has been described on MRI in zone (7). Blondel et al. also reported search reveals numerous studies patients with poliomyelitis (3). Oishi that affection of intermediate zone confirming the presence of postvac- et al. reported postvaccinal poliomy- and even the posterior gray column cinal acute disseminated encephalo- elitis affecting the anterior horn and could be present in severe cases (8). myelitis. However, only 37 patients showing postcontrast enhancement, The posterior horn receives several have been reported in the literature that did not improve on intravenous types of sensory information from having isolated postvaccinal trans- immunoglobulin treatment (4), while the body including proprioception verse myelitis (12). Majority of these Choudhary et al. reported poliomy- and vibration. This is the most likely patients had a history of recently elitis with both brain and spinal cord reason why our patient presented al- administered hepatitis B, measles- affection, presented with subacute tered proprioception, clinically con- mumps-rubella, diphteria-tetanus- onset of flaccid paralysis, associated fused by infectologist with ataxia pertussis and other vaccines. Only 3 with bilateral changes in substantia and possible cerebellitis. out of 37 patients had a history of nigra and anterior horns of the spinal Increased T2 signal of the anterior recent oral polio vaccination. cord gray matter (5). However, the horns is not only pathognomonic Transverse myelitis is an acute in- involvement of both anterior and for poliomyelitis. Hopkins syndrome, flammatory condition, of idiopathic, posterior horns of the spinal cord also associated with flaccid paraly- postinfectious, postvaccinal or dis- gray matter in our patient were clear sis, and Lyme neuroboreliosis affect ease-associated etiology, typically on axial T2-weighted images and anterior horns, presented with ele- involving thoracic segment of the diffusion-weighted sequences. To vated signal on T2-weighted imag- spinal cord. MRI usually reveals a the best of our knowledge, no radio- es (9, 10). Kraushaar et al. reported a long, centrally located intramedul- logical contributions exist, confirm- serologically proved West Nile virus lary lesion, extending over 3 verte- ing the involvement of both anterior flaccid paralysis of right upper ex- bral segments, and involving com- and posterior horns of the spinal tremity associated with striking T2 plete or the most of the cross section cord gray matter in patients with hyperintensity in the anterior horns of the cord (13). poliomyelitis or oral polio vaccine of the cervical spinal cord, similar to Our patient recovered completely induced transverse myelitis. Histo- those seen in cases of poliomyeli- with regression of all clinical symp- pathologically proven invasion of tis (11). toms. Recovery is patients with the posterior horns was reported in The main limitation of this report poliomyelitis is usually completed 1951 by Harrer and Niedermeyer (6). is the fact that polimerase chain in six to eight months. Paralysis In 2013, Kosaka et al. reported the reaction was not available at the remaining after one year is likely to presence of post-polio syndrome in institution were the child had been be permanent, although modest a 77-year-old who presented with initially admitted. It remained un- recoveries of muscle strength are neuromuscular problems many years clear if the spinal cord inflammation possible 12 to 18 months after infec- after acute poliomyelitis, mimicking was compatible with infectious pro- tion (14). Strebel et al. reported that

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