What are the signs and symptoms of transverse myelitis?

Signs and Symptoms of MOGAD Transverse Myelitis

MOGAD-associated transverse myelitis presents with acute or subacute bilateral motor weakness, sensory disturbances, and autonomic dysfunction (particularly bladder and bowel dysfunction), typically with spastic paralysis and increased deep tendon reflexes due to upper motor neuron involvement. 1

Motor Manifestations

• Bilateral weakness develops rapidly over hours to days, most commonly progressing to maximal severity within 10 days of symptom onset 1, 2
• Spastic paralysis with hyperreflexia (increased deep tendon reflexes) is characteristic, distinguishing it from lower motor neuron disorders like Guillain-Barré syndrome which presents with flaccid paralysis 1
• At peak deficit, approximately 50% of patients develop complete paraplegia with no volitional leg movements 3
• Incomplete, painful tetraparesis may occur when cervical cord segments are involved 4

Sensory Symptoms

• Numbness, paresthesias, or band-like dysesthesias occur in 80-94% of patients at peak deficit 3
• Sensory level corresponding to the spinal cord lesion location 1, 2
• Lower limb pain is common, particularly when the conus medullaris and cauda equina are affected 4

Autonomic Dysfunction

• Bladder dysfunction is nearly universal, occurring in virtually all patients with transverse myelitis 1, 3
• Urinary retention is a common manifestation requiring evaluation 1
• Bowel dysfunction and constipation frequently accompany bladder symptoms 1
• Severe erectile and sphincter disturbance may occur, particularly with conus medullaris involvement, which is especially suggestive of MOG-EM 4, 5

MOGAD-Specific Features

• Longitudinally extensive transverse myelitis (LETM) affecting ≥3 vertebral segments is common in MOGAD, occurring in 44-52% of patients during their disease course 5
• In pediatric MOG-EM patients, LETM is present at disease onset in 80% of cases 5
• Conus medullaris involvement at disease onset is particularly suggestive of MOGAD 5
• Severe and recurrent myelitis episodes, even when non-longitudinally extensive, should raise suspicion for MOGAD 4

Clinical Course Characteristics

• Steroid-responsive symptoms with flaring after tapering or discontinuation of corticosteroids is characteristic of MOGAD 4
• Symptoms typically evolve over hours to days, reaching maximal clinical severity within 10 days 1, 2
• Good response to plasma exchange (PEX) when steroids are insufficient 4

Associated Features That Suggest MOGAD

• Bilateral optic neuritis occurring simultaneously or sequentially with myelitis 4
• Brainstem involvement extending from the spinal cord lesion 4
• ADEM-like presentation with large white matter lesions, disturbance of consciousness, and involvement of the entire spinal cord 4
• Absence of oligoclonal bands in CSF (87-88% of MOG-EM patients) 5
• CSF pleocytosis with lymphomonocytic cells and neutrophils (up to 10%), with negative oligoclonal bands 4

Important Clinical Pitfalls

• The presence of increased deep tendon reflexes is the key distinguishing feature from conditions causing flaccid paralysis like Guillain-Barré syndrome 1
• Multiple sclerosis rarely if ever presents with LETM; when LETM is present, alternative diagnoses like MOGAD or NMOSD should be strongly considered 5
• Fever is typically absent in MOGAD transverse myelitis, unlike infectious causes 4
• Symptoms may initially appear mild but can progress rapidly, making early recognition critical 1, 6