What is the best course of action for a patient with longitudinally extensive transverse myelitis, presenting with bilateral lower extremity weakness, failure to pass urine and feces, bilateral flank pain, paresthesia, hyponatremia, and leukopenia, and who is currently on omeprazole, prednisolone, bisacodyl, warfarin, unfractionated heparin, metoclopramide, and morphine?

Management of Longitudinally Extensive Transverse Myelitis with Severe Complications

This patient requires immediate high-dose intravenous methylprednisolone 1g daily for 3-5 days combined with IVIG 2g/kg over 5 days, with urgent neurology consultation and ICU-level monitoring given the severe presentation with complete urinary/bowel retention and bilateral lower extremity paralysis. 1, 2

Immediate Actions (Within Hours)

Discontinue Potentially Causative Medications

• Stop warfarin and unfractionated heparin immediately - these anticoagulants pose significant hemorrhagic risk in the setting of acute spinal cord inflammation and the patient already has concerning leukopenia 3, 1
• Continue prednisolone temporarily until high-dose pulse steroids are initiated 1

Initiate Aggressive Immunosuppressive Therapy

• Administer methylprednisolone 1g IV daily for 3-5 days as first-line treatment - this is the cornerstone of acute LETM management and delays beyond 2 weeks worsen prognosis 1, 2, 4
• Add IVIG 2g/kg divided over 5 days (0.4g/kg/day) concurrently - combination therapy is recommended for severe presentations with motor weakness and sphincter dysfunction 3, 1, 2
• The severity of this presentation (bilateral paralysis, complete urinary/fecal retention, paresthesia) mandates combination therapy rather than steroids alone 1, 2

Critical Monitoring and Support

• Transfer to ICU-level care immediately - patients with LETM can develop ascending paralysis affecting respiratory muscles, particularly when lesions extend to cervical segments 3, 4
• Monitor respiratory function closely with serial vital capacity and negative inspiratory force measurements 3
• The case report of a patient developing type 2 respiratory arrest 30 hours after admission with LETM extending from C2 to conus medullaris demonstrates this risk 4

Diagnostic Workup (Concurrent with Treatment)

Essential Serological Testing

• Aquaporin-4 IgG antibodies - positive results indicate neuromyelitis optica spectrum disorder (NMOSD) requiring more aggressive long-term immunosuppression 1, 2, 5
• MOG-IgG antibodies - identifies MOG-antibody disease with different treatment implications 2
• Complete autoimmune panel including ANA, Ro/La, anti-dsDNA 3, 1
• Infectious workup: HIV, RPR, viral PCRs 3, 1
• Vitamin B12, TSH, thyroid peroxidase antibodies 3, 1

CSF Analysis via Lumbar Puncture

• Cell count, protein, glucose, oligoclonal bands 3, 1, 6
• Viral PCRs including JCV to exclude progressive multifocal leukoencephalopathy 3
• Onconeural antibodies and paraneoplastic panel 3, 1

Imaging Confirmation

• MRI already shows LETM (≥3 vertebral segments involved), which is the defining radiologic feature 2, 7, 5
• Ensure brain MRI with contrast is obtained to evaluate for additional demyelinating lesions suggesting multiple sclerosis or NMOSD 3, 1

Management of Concurrent Complications

Hyponatremia Correction

• Correct hyponatremia cautiously (no faster than 8-10 mEq/L per 24 hours) to avoid osmotic demyelination syndrome 1
• This is particularly critical given existing spinal cord demyelination 1

Leukopenia Investigation

• Urgent hematology consultation - leukopenia may represent bone marrow suppression, autoimmune process, or infection 1
• Hold bisacodyl and metoclopramide temporarily as these can rarely cause cytopenias 1
• Check peripheral smear, reticulocyte count, and consider bone marrow biopsy if severe or unexplained 1

Bladder and Bowel Management

• Initiate intermittent catheterization for urinary retention rather than indwelling catheter to reduce infection risk 3, 1, 8
• Aggressive bowel regimen with scheduled enemas given complete fecal retention 3, 1
• Evaluation for autonomic dysfunction is essential as this affects up to 90% of transverse myelitis patients 8, 9, 6

Pain Management

• Continue morphine for neuropathic pain initially 1
• Consider transitioning to neuropathic pain agents (gabapentin, pregabalin, or duloxetine) once acute phase stabilizes 3

Second-Line Therapies (If No Response in 3-7 Days)

Plasma Exchange

• Initiate plasmapheresis if no improvement or worsening after 3 days of methylprednisolone plus IVIG 3, 1, 2
• Plasma exchange has shown benefit in steroid-refractory cases 1, 2

Rituximab Consideration

• Reserve for cases with positive autoimmune antibodies (aquaporin-4, MOG) or inadequate response to steroids, IVIG, and plasma exchange 3, 1, 2

Steroid Tapering and Maintenance

Acute Phase Taper

• After 3-5 days of pulse methylprednisolone, transition to oral prednisone 1mg/kg daily 3, 1
• Taper over minimum 4-6 weeks - rapid tapering increases relapse risk which occurs in 50-60% of cases 3, 1

Long-Term Immunosuppression

• Maintenance therapy with azathioprine or other immunosuppressant is necessary to prevent relapses during steroid taper 1
• If aquaporin-4 positive (NMOSD), consider rituximab, azathioprine, or mycophenolate mofetil for long-term prevention 1, 2, 5

Prognostic Considerations

Poor Prognostic Indicators Present in This Case

• Longitudinally extensive lesion (≥3 vertebral segments) - associated with worse outcomes 1, 2, 5
• Complete sphincter dysfunction at presentation - indicates severe cord involvement 1, 8
• Bilateral lower extremity paralysis - severe motor deficit predicts incomplete recovery 1, 9, 6

Critical Timing Factor

• Delay beyond 2 weeks in initiating therapy significantly worsens prognosis - this patient requires treatment within hours, not days 1
• Two-thirds of transverse myelitis patients have moderate to severe residual disability, emphasizing the urgency of aggressive early treatment 9, 6

Key Clinical Pitfalls to Avoid

• Do not wait for complete diagnostic workup before initiating treatment - the combination of clinical presentation and MRI findings is sufficient to begin therapy 1, 4, 6
• Do not use steroids alone in severe cases - this patient's presentation mandates combination therapy with IVIG 1, 2
• Do not overlook respiratory monitoring - ascending paralysis can occur rapidly, particularly with cervical involvement 3, 4
• Do not continue anticoagulation without compelling indication - hemorrhagic transformation of spinal cord lesions is a recognized complication 1