Transverse Myelitis
The most likely diagnosis is C- Transverse myelitis, given the acute bilateral lower limb weakness, T10 sensory level, urinary incontinence, and history of previous infection—all occurring without back pain, which is the critical distinguishing feature that makes spinal cord compression unlikely. 1
Key Diagnostic Features Supporting Transverse Myelitis
The clinical presentation is pathognomonic for spinal cord pathology at the T10 level:
- The T10 sensory level indicates spinal cord involvement, not peripheral nerve or cauda equina pathology 1, 2
- Acute bilateral lower limb weakness with sensory level and urinary retention developing over 3 days is characteristic of transverse myelitis 1, 3
- The history of previous infection is a critical clue, as approximately two-thirds of transverse myelitis cases follow an infectious prodrome 3, 4
- The absence of back pain is the most important distinguishing feature—spinal cord compression typically presents with significant, often severe back pain as a prominent early symptom, which is notably absent here 1, 2
Why Other Diagnoses Are Less Likely
Spinal cord compression (Option A) is unlikely:
- Back pain is typically present and severe in compressive myelopathy, but is absent in this case 1, 2
- While compression can cause similar motor and sensory findings, the lack of pain and the post-infectious context strongly favor an inflammatory rather than compressive etiology 2, 3
Guillain-Barré syndrome (Option B) is unlikely:
- GBS presents with ascending weakness starting distally in the legs and progressing upward over days to weeks 5, 2
- GBS causes areflexia due to peripheral nerve involvement, not a defined sensory level 1, 2
- A clear T10 sensory level indicates spinal cord pathology, which does not occur in GBS 1
- Urinary retention is uncommon in early GBS, whereas it is characteristic of transverse myelitis 1, 6
Cauda equina syndrome (Option D) is unlikely:
- The T10 sensory level is too high for cauda equina syndrome, which affects lumbosacral nerve roots below L1-L2 1, 2
- Cauda equina causes lower motor neuron signs with areflexia, not the upper motor neuron pattern expected with a T10 cord lesion 2
- Severe back pain is typically present in cauda equina syndrome but is absent here 1
Immediate Management Priorities
Urgent MRI of the entire spine is mandatory:
- MRI should be obtained immediately to confirm the diagnosis and exclude compressive lesions 2, 3
- Typical MRI findings show T2 hyperintense signal changes extending for at least three spinal segments 7, 6, 4
- Do not delay imaging, as differentiation between compressive and inflammatory myelopathy is critical 2, 3
Initiate high-dose intravenous methylprednisolone promptly:
- Treatment should begin as soon as the diagnosis is confirmed, as outcomes are time-dependent 1, 4
- One case series demonstrated significant neurological improvement with IV methylprednisolone therapy 4
Perform comprehensive etiologic workup:
- Infectious workup including viral serologies (especially in endemic areas for Schistosoma, Lyme disease) is essential given the history of previous infection 1, 7
- Autoimmune screening for neuromyelitis optica, multiple sclerosis, and systemic autoimmune diseases is necessary 1
- Lumbar puncture typically shows elevated protein with normal glucose and white blood cell count 4
Common Pitfalls to Avoid
- Do not assume the absence of back pain rules out all spinal pathology—it specifically helps distinguish transverse myelitis from compression 1
- Do not delay treatment waiting for complete workup—initiate steroids once imaging excludes compression 1, 3
- Do not overlook bladder dysfunction as a key feature—urinary retention is common in acute transverse myelitis and may persist long-term, requiring urodynamic evaluation 6, 8
budget:token_budget Tokens used this turn: 4407 Tokens remaining: 195593