What are the contraindications for steroid treatment in transverse myelitis?

Contraindications for Steroid Treatment in Transverse Myelitis

High-dose intravenous methylprednisolone is the first-line treatment for transverse myelitis, but is contraindicated in patients with active systemic fungal infections, untreated tuberculosis, active hepatitis B infection, and in those with known strongyloidiasis or amebiasis. 1, 2

Absolute Contraindications

• Active systemic fungal infections: Corticosteroids exacerbate systemic fungal infections and should be avoided unless needed to control drug reactions 2
• Untreated tuberculosis: May lead to dissemination of infection
• Active hepatitis B infection: Corticosteroids can cause reactivation of hepatitis B virus 2
• Known strongyloidiasis (threadworm) infestation: Can lead to hyperinfection and potentially fatal gram-negative septicemia 2
• Active amebiasis: Corticosteroids may activate latent amebiasis 2
• Cerebral malaria: Corticosteroids should be avoided in patients with cerebral malaria 2

Relative Contraindications (Requiring Special Precautions)

• Exposure to varicella or measles in non-immune patients: Requires prophylaxis with varicella zoster immune globulin or immunoglobulin respectively 2
• Pregnancy: Benefits must be weighed against potential hazards to mother and fetus; IVIG may be preferred in pregnant patients 1, 2
• Active infection: Rule out infectious causes before starting immunosuppression 1
• Uncontrolled hypertension: Steroids can cause elevation of blood pressure 2
• Uncontrolled diabetes: May worsen glycemic control
• Severe osteoporosis: May accelerate bone loss
• Recent vaccination with live or attenuated vaccines: Administration of these vaccines is contraindicated in patients receiving immunosuppressive doses of corticosteroids 2

Special Considerations

1. For immune checkpoint inhibitor-related myelitis:

   • Permanently discontinue the immunotherapy agent before starting steroids 1

2. For antiphospholipid antibody-positive patients:

   • Consider anticoagulation therapy in addition to steroids 1

3. For SLE-associated transverse myelitis:

   • IV methylprednisolone combined with IV cyclophosphamide is recommended 1, 3

4. For patients with severe disease:

   • Consider combination therapy with methylprednisolone plus IVIG or plasma exchange from the beginning 1

Monitoring Requirements During Steroid Treatment

• Blood pressure: Monitor for hypertension
• Blood glucose: Monitor for hyperglycemia
• Electrolytes: Particularly potassium levels due to increased excretion 2
• Signs of infection: Due to immunosuppressive effects
• Ophthalmic effects: Prolonged use may lead to cataracts, glaucoma, and secondary ocular infections 2

Risk Mitigation Strategies

• Screen patients for hepatitis B infection before initiating prolonged treatment 2
• Consider salt restriction and potassium supplementation 2
• For patients at risk of strongyloidiasis, screen and treat before starting steroids
• For patients requiring vaccination, note that response to killed or inactivated vaccines may be diminished 2

Early initiation of steroid therapy (within the first few hours after diagnosis) is crucial for improving outcomes in transverse myelitis, with delays beyond 2 weeks associated with severe neurological deficits 1. Despite contraindications, the benefits of prompt treatment often outweigh the risks in this potentially devastating condition.