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Idiopathic Recurrent Transverse Myelitis

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ORIGINAL CONTRIBUTION Idiopathic Recurrent Transverse Myelitis Kwang-kuk Kim, MD, PhD Objective: To determine whether idiopathic recurrent resonance imaging features (involved spinal cord seg- transverse myelitis (RTM) can be distinguished from mul- ments in T2-weighted images and gadolinium tiple sclerosis–associated RTM (MSRTM) on the basis of 64–enhanced lesions on T1-weighted images), IgG clinical manifestations of myelopathy, or findings from index, and oligoclonal bands in cerebrospinal fluid were magentic resonance imaging or cerebrospinal fluid ex- compared. amination. Result: Idiopathic RTM occurred preponderantly in Design: A retrospective analysis of 37 cases was con- male patients and presented more often with acute ducted. Patients were classified as having idiopathic RTM transverse myelitis than did MSRTM. More than 2 on the basis of recurrent myelitis confirmed by clinical mani- relapses occurred in 6 cases (40%) of idiopathic RTM. festations of myelopathy and magnetic resonance imaging The involved segments of spinal cord on T2-weighted findings. On review patients with idiopathic RTM had nor- images were not significantly different in idiopathic mal cranial magnetic resonance imagings and did not dem- RTM and MSRTM, with enhancing lesions mostly in onstrate paraclinical evidence of spatial dissemination be- the posterior columns, and the spinothalamic and spi- yond the spinal cord of the disease process. Patients were nocerebellar tracts of white matter. Additionally, almost classified as having MSRTM on the basis of criteria of Poser all patients with idiopathic RTM had normal cerebro- et al for clinically definite multiple sclerosis involving the spinal fluid indexes. central nervous system. Fifteen patients met study criteria for idiopathic RTM. Twenty-two patients had MSRTM. Conclusion: Idiopathic RTM might be a disease entity distinct from MSRTM, differing in its male preponder- Setting: Asan Medical Center, Seoul, South Korea, from ance, absence of oligoclonal bands, frequent multiple re- January 1, 1992, through December 31, 2001. lapses, and frequent presentation as acute transverse my- elitis. Main Outcome Measures: Presenting symptoms and clinical manifestations, relapsing times, magnetic Arch Neurol. 2003;60:1290-1294 ECURRENT TRANSVERSE my- gin are clearly defined and that include long- elitis (RTM) usually her- term follow-up are needed to distinguish alds or is accompanied by le- idiopathic RTM from MS-associated RTM sions producing dysfunction (MSRTM). In this study, the medical re- elsewhere in the central ner- cords of 15 patients with idiopathic RTM vous system and almost always signifies the who were followed up for longer than 5 R 1-4 presence of multiple sclerosis (MS). A se- years after their first attack of myelitis were ries of 3 cases of RTM in patients who never reviewed for clinical manifestations, spe- developed other evidence of MS or colla- cific spinal MRI findings, and CSF study gen vascular disease and had no abnormali- results to verify a novel disease entity dis- ties on magnetic resonance imagings (MRIs) tinguished from clinically definite myelo- of the brain suggested that RTM may be a pathic MS. disorder distinct from MS.5 Recurrent trans- verse myelitis as an independent entity, with METHODS neither abnormal cranial MRI nor oligo- The medical records of 15 consecutive pa- From the Department of clonal bands (OCBs) in cerebrospinal fluid tients (12 men and 3 women) with idiopathic Neurology, University of Ulsan (CSF), is an interesting topic in terms of the RTM were reviewed. Diagnostic criteria for id- College of Medicine, Asan causative factors and therapeutic consider- iopathic RTM consisted of 2 or more attacks Medical Center, Seoul, South ations. Further studies in which the crite- at different neuroanatomically distinct spinal Korea. ria for an idiopathic RTM of unknown ori- cord levels without association with a febrile (REPRINTED) ARCH NEUROL / VOL 60, SEP 2003 WWW.ARCHNEUROL.COM 1290 ©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Clinical Data, Spinal Cord Magnetic Resonance Imaging (MRI) Findings, and Cerebrospinal Fluid Profiles in Patients With Idiopathic RTM or MSRTM Spinal MRI Finding Presentation Patient No./ T2WI First/ Interval Between First Symptoms Myelopathy No. of Relapses IgG Index Sex/Age, y Second Attack T1WI Enhanced Lesion and Second Attack, mo First/Second Attack of Myelitis (Ͼ0.7)/OCBs Patients With IRTM* 1/M/50 T5-7/ T9-10 NA 36 ATM/PTM 2 0.6/− 2/M/41 T10-11/ T6 2nd: T6 (R ST) 31 PTM/PTM 3 0.54/− 3/M/45 C7-T1/ T4-5 NA 13 PTM/PTM 3 0.12/− 4/M/33 T3-5/C7-T2 2nd: C7, T2 (PC and SC) 1 ATM/PTM 4 1.00/− 5/M/56 C5/ T4-5 1st: (C5 CS) 1 PTM/PTM 2 0.50/− 6/M/48 C1-6/ T1-3 2nd: T2-3 (R ST and PC) 2 ATM/PTM 2 0.40/− 7/F/36 C1-3/ T6-9 NA 28 PTM/ATM 3 0.47/− 8/M/36 T7-8/ T6-7 2nd: T6-7 (L SC and PC) 5 PTM/PTM 2 ND/ND 9/M/38 C1-3/C2-5 NA 8 PTM/PTM 3 0.72/− 10/M/59 T2-6/ T2-4 1st: T6 (PC and L SC) 7 PTM/PTM 2 0.57/− 11/M/43 C7-T1/ T6-12 NA 7 PTM/PTM 2 ND/ND 12/M/42 T5-7/ T3-5 1st: T5 and T7 (PC) 15 PTM/PTM 2 0.45/− 13/M/48 C7-T1/C7-T1 NA 13 PTM/PTM 2 ND/ND 14/F/29 T5-6/ T4-6 NA 13 PTM/ATM 2 0.80/− 15/F/43 T4-6/C1-3 NA 29 ATM/PTM 4 0.40/− Patients With MSRTM† 1/F/62 C1-4/C2-T1 1st: C3, 4 (R PC, SCT, and STT) 59 PTM/PTM 2 0.54/− 2/F/26 C2/C7-T1 1st: C2; 2nd: T1 (PC, CST, and SCT) 35 PTM/PTM 3 0.50/− 3/F/45 C4-7/ T6-8 1st: C4, 6 (L, SCT, and STT) 3 PTM/PTM 2 0.54/+ 4/F/19 C3-6/ T5-6 1st: C4; 2nd: T5 (PC and CS) 30 PTM/PTM 3 0.71/− 5/M/35 C3/C7-T1 NA 13 PTM/PTM 2 0.50/− 6/F/39 T5-6/ T5-6 NA 1 PTM/PTM 2 1.87/+ 7/F/48 T4-5/ T10 NA 21 PTM/PTM 2 ND 8/M/44 T3-7;T9-10 NA 22 PTM/PTM 2 ND 9/M/51 T8-10/ T9-11 NA 2 PTM/PTM 2 0.51/− 10/F/47 C2-6/ T4-5 1st: C2, 3 (PC and STT) 11 PTM/PTM 2 0.40/+ 11/M/50 T2-5/ T8-9 NA 246 PTM/PTM 2 0.72/− 12/F/23 C1-4/ T5-8 1st: C3, 4 (R PC) 3 PTM/PTM 2 1.12/+ 13/F/27 C1-5/ T4 NA 1 PTM/PTM 2 0.99/− 14/F/48 C1-6/ T4-12 NA 28 PTM/ATM 2 0.5/+ 15/F/41 C1-7/ T4-7 1st: C3, 5; 2nd: T4 (PC and SCT) 13 PTM/PTM 2 0.98/+ 16/F/48 C1-7/ T2-5 1st: C2, 5 (PC) 2 PTM/PTM 2 1.2/− 17/M/42 T7/Conus NA 19 PTM/PTM 2 2.52/+ 18/F/50 C3-5/C5-7 NA 12 PTM/PTM 2 4/− 19/M/37 T4-5/ T7-8 NA 14 PTM/PTM 2 0.51/− 20/F/38 T1-3/ T6 NA 9 PTM/PTM 2 0.49/− 21/F/28 C4-6/C6 1st: C5 (R STT) 1 PTM/PTM 2 0.42/− 22/F/33 T8-10/C2-7 2nd: C2, 6 (PC) 46 PTM/PTM 2 0.69/− Abbreviations: ATM, acute transverse myelitis defined as a spinal cord syndrome characterized by paraplegia with or without sensory symptoms and bladder dysfunction; IRTM, idiopathic RTM; MSRTM, multiple sclerosis–associated RTM; NA, not applicable; ND, not determined; OCBs, oligoclonal bands; PC, posterior column; PTM, partial transverse myelitis; RTM, recurrent transverse myelitis; SCT, spinocerebellar tract; STT, spinothalamic tract; T1WI, T1-weighted image; T2WI, T2-weighted image; minus sign, absent; plus sign, present. *The mean follow-up time for the idiopathic RTM group is 5.9 years. †The mean follow-up time for the MSRTM group is 7.0 years. illness, each lasting over 24 hours and confirmed by both high rus and hepatitis B or A, VDRL, polymerase chain reaction of signal intensity of the T2-weighted image (T2WI) at the re- tuberculosis, and spinal tap in the first 24 hours were per- sponsible spinal cord level and a normal MRI of the brain within formed in all patients. All 15 patients had MRIs of the spinal 7 days of an episode.5-7 Patients were excluded if there was a cord and brain during each attack. The mean age for patients history of recent carcinoma, abdominal surgery radiation with idiopathic RTM was 43 years. therapy, epidural spinal block, arteriovenous malformation of Patients in the MSRTM group consisted of 22 consecu- the spinal cord, paraneoplastic spinal cord syndrome with or tive patients (6 men and 16 women) with onset of MS symp- without paraneoplastic antibodies (anti-Hu, anti–collapsin re- toms referable to the spinal cord, optic nerve, or brainstem, all sponse-mediated protein 58), or clinically definite myelo- of whom eventually had RTM and fulfilled criteria by Poser et pathic MS. Patients with systemic lupus erythematosus or Sjo¨- al9 for clinically definite MS. The mean age for patients with gren syndrome were also excluded. If the results of an antinuclear MSRTM was 41 years. All patients underwent MRI of the brain antibody test were positive, anti–double-strain DNA, antisolu- and spinal cord.
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