What is the treatment for transverse myelitis?

Treatment of Transverse Myelitis

High-dose intravenous corticosteroids (methylprednisolone 1g/day for 3-5 days) followed by immunosuppressive therapy is the first-line treatment for transverse myelitis, with additional therapies such as IVIG, plasma exchange, or rituximab considered for moderate to severe or refractory cases. 1, 2

Diagnostic Approach

• Neurologic consultation should be obtained promptly for all suspected cases of transverse myelitis 1, 2
• MRI of the spine with thin axial cuts through the region of suspected abnormality is essential to confirm diagnosis and rule out cord compression 1, 2
• Lumbar puncture should be performed to check cell count, protein, glucose, oligoclonal bands, viral PCRs, and onconeural antibodies 1
• Blood tests should include B12, HIV, RPR, ANA, Ro/La, TSH, and aquaporin-4 IgG to rule out other causes and associated conditions 1, 2
• Evaluation for urinary retention and constipation is important as these are common autonomic manifestations 1

First-Line Treatment

• Permanently discontinue any immune checkpoint inhibitors if transverse myelitis develops during cancer treatment 1
• Administer high-dose intravenous methylprednisolone (1g/day for 3-5 days) as soon as possible after diagnosis 1, 2
• For SLE-related transverse myelitis, combine intravenous methylprednisolone with intravenous cyclophosphamide for better outcomes 1, 3
• Treatment should be initiated promptly, ideally within the first few hours of symptom onset, as delay (>2 weeks) is associated with poorer outcomes 1

Second-Line and Adjunctive Therapies

• Intravenous immunoglobulin (IVIG) should be strongly considered for moderate to severe cases (2 g/kg over 5 days) 1, 2
• Plasma exchange therapy should be considered in severe cases not responding to corticosteroids and immunosuppressants 1, 2
• For refractory cases, especially those positive for autoimmune antibodies, rituximab may be beneficial 1, 2
• Anticoagulation therapy should be considered in antiphospholipid-positive myelopathy 1

Disease-Specific Considerations

• For schistosomiasis-associated transverse myelitis, praziquantel is the treatment of choice, with corticosteroids started one day before anthelmintic treatment 1
• For neurotoxocariasis presenting with myelitis, albendazole for 3-4 weeks with corticosteroids is recommended 1
• In SLE-related myelopathy, maintenance immunosuppressive therapy (usually azathioprine) is necessary after initial treatment due to high relapse rates (50-60%) 1, 3

Prognostic Factors

• Factors associated with poor outcomes include:
  • Extensive spinal cord MRI lesions 1
  • Reduced muscle strength or sphincter dysfunction at presentation 1
  • Presence of antiphospholipid antibodies 1
  • Delay (>2 weeks) in initiating therapy 1

Follow-up and Monitoring

• Neurological response should be monitored and typically parallels MRI improvement within a few days to 3 weeks 1
• Maintenance immunosuppressive therapy is often required, particularly in autoimmune-associated transverse myelitis, to prevent relapses 1, 3
• Regular assessment of neurological function, including motor strength, sensory changes, and autonomic function is essential 2

Common Pitfalls

• Failure to initiate treatment promptly can lead to permanent neurological deficits 1
• Overlooking associated conditions (like SLE, antiphospholipid syndrome, or neuromyelitis optica) can lead to incomplete treatment 1, 2
• Inadequate duration of immunosuppressive therapy can result in relapses, especially in SLE-related myelitis 1, 3
• Not screening for infectious causes before starting immunosuppression can worsen outcomes in infection-related cases 1