History-Taking Approach in Pediatric Transverse Myelitis
When evaluating a child with suspected transverse myelitis, focus your history on the temporal pattern of symptom onset, specific neurological deficits, preceding infections, and associated systemic features to distinguish between idiopathic TM, demyelinating disorders, and acute flaccid myelitis.
Temporal Pattern and Symptom Progression
Document the precise timeline of symptom evolution, as transverse myelitis typically manifests over hours to 1 week 1. This rapid progression distinguishes TM from other chronic conditions:
- Onset timing: Record when symptoms began and how quickly they progressed (hours versus days) 2, 1
- Peak severity: Identify when symptoms reached maximum intensity, as most cases plateau within days 1
- Progression pattern: Note whether symptoms are ascending, descending, or simultaneous in distribution 2
Core Neurological Symptoms
Systematically elicit the four cardinal manifestations that define the clinical syndrome 2:
Motor Deficits
- Weakness pattern: Upper extremities, lower extremities, or both 2, 3
- Severity: Mild weakness versus complete paralysis 3
- Flaccid versus spastic: Flaccid paralysis with electrophysiological evidence of axonal loss suggests worse prognosis 3
Sensory Alterations
- Sensory level: Identify the dermatomal level where sensation changes (e.g., T5) 4
- Type of sensory loss: Numbness, paresthesias, or pain 2
- Distribution: Bilateral versus unilateral involvement 2
Autonomic Dysfunction
- Bladder dysfunction: Urinary retention or incontinence 2, 4
- Bowel dysfunction: Fecal retention or incontinence 2, 4
- Other autonomic features: Document any temperature dysregulation or blood pressure instability 2
Pain Symptoms
- Back pain: Location and severity 4
- Radicular pain: Nerve root distribution suggesting peripheral involvement 3
- Visceral pain: Epigastric or abdominal pain may accompany autonomic dysfunction 4
Preceding Events and Infectious Triggers
Inquire about recent infections occurring days to weeks before symptom onset, as post- or parainfectious inflammation is the most frequent cause 1:
- Respiratory infections: Upper respiratory symptoms, COVID-19 exposure or positive testing 4
- Gastrointestinal infections: Diarrhea or vomiting 1
- Fever: Document timing relative to neurological symptoms 4
- Recent vaccinations: Record type and timing 1
- Viral prodrome: Nonspecific viral symptoms preceding paralysis 2, 1
Associated Systemic and CNS Features
Identify features suggesting specific etiologies or multi-focal disease 2, 5:
Multi-focal CNS Involvement
- Encephalopathy: Altered mental status, seizures, or behavioral changes suggesting ADEM 3
- Optic neuritis: Vision changes suggesting NMOSD or MS 2
- Brainstem symptoms: Cranial nerve deficits, ataxia, or dysarthria 2
- Cerebral symptoms: Headache, confusion, or focal neurological signs 3
Multi-systemic Disease Features
- Rash: Malar rash or photosensitivity suggesting lupus 5
- Joint symptoms: Arthritis or arthralgias 5
- Constitutional symptoms: Weight loss, night sweats, or fatigue 5
- Oral/genital ulcers: Suggesting Behçet's disease 5
Past Medical History and Risk Factors
Prior Neurological Events
- Previous episodes: History of optic neuritis, myelitis, or other demyelinating events suggesting relapsing disorder 2, 5
- Multiple sclerosis: Family history or personal history of MS 5
- Autoimmune conditions: Systemic lupus erythematosus, Sjögren's syndrome, or other connective tissue diseases 5
Developmental and Cognitive Baseline
- Premorbid cognitive ability: Establish baseline functioning, as lower cognitive ability may affect prognosis and rehabilitation 6
- Learning difficulties: Pre-existing educational challenges 6
- Psychiatric history: Anxiety, depression, or behavioral disorders 6
Social and Environmental Factors
- Family stressors: Document psychosocial factors that may impact recovery 6
- Socioeconomic status: Lower SES associated with worse outcomes in neurological conditions 6
- Recent travel: Exposure to endemic infections 1
Medication and Immunization History
- Recent medications: Particularly immunosuppressants or biologics 5
- Vaccination history: Recent immunizations within 4-6 weeks 1
- Antibiotic use: May suggest preceding bacterial infection 1
Critical Pitfalls to Avoid
Do not delay imaging to obtain history if spinal cord compression is suspected 1. The history should be obtained concurrently with urgent diagnostic workup, not sequentially.
Distinguish acute flaccid myelitis from typical TM by specifically asking about asymmetric limb weakness and preceding viral illness, as AFM has distinct treatment implications and worse prognosis 2, 3.
Recognize that some etiologies can only be proven by follow-up examination, so document the initial presentation meticulously for longitudinal comparison 1. Relapsing disorders like NMOSD may present identically to idiopathic TM at first episode 2.
In the current era, specifically ask about COVID-19 exposure and testing, as post-COVID-19 TM is now recognized in pediatrics with potentially severe outcomes 4.