In parainfectious ATM, IgM serology is positive or IgG levels are fourfold or greater on two successive tests for a specific infectious agent.
The etiology of acute-onset transverse myelitis remains unknown. In 30-60% of patients there is an antecedent respiratory, gastrointestinal or systemic illness. Neurological injury may be associated with direct infection or remote infection followed by a systemic response causing neurological damage.
Individual sporadic cases of transverse myelitis have been described following intrathecal pump insertion, spinal, epidural anaesthesia and even after general anaesthesia. (6-9) The cases observed after intrathecal pump insertion were caused by Acinetobacter baumanii. When the condition developed following spinal, epidural or general anaesthesia, the causative agent could not be identified. (6-10)
In our patient, the diagnosis of acute bacterial transverse myelitis of the thoracic spinal cord was made on the basis of sudden neurologic disability, CSF analysis and MRI of the spinal cord in association with systemic signs of inflammation. Neurologic deficit appeared quickly with high paraplegia. CSF analysis showed normal glucose, high leucocyte count and increased protein, which is characteristic for bacterial transverse myelitis. A bacterial pathogen was not identified since the epidural catheter had been removed on account of pruritus three days before the onset of symptoms. Culture of cerebrospinal fluid yielded no organisms. At the time of lumbar puncture, the patient was treated with ciprofloxacin and clindamycin, which might explain why his cerebrospinal fluid was sterile. Subsequently, the antibiotic therapy was changed to ceftazidime and vancomycin, which were selected on a purely empirical basis but proved appropriate, leading to a decrease in inflammatory parameters.
The suitability of anti-oedema therapy in transverse myelitis is a matter of debate. Our patient received dexamethasone 8 mg/8h . for three weeks. According to the literature, higher doses of methylprednisolone (1 g/day for three days, followed by a gradual decrease) have been used with success in a small number of patients. (6-8) Since acute transverse myelitis may have an autoimmune etiology, immunosuppression seems reasonable.
In conclusion, difficult, traumatic puncture of the epidural space may lead to the development of an extradural haematoma, which can act as a nidus for infection. A good aseptic technique is of paramount importance. This includes using a sterile gown, sterile gloves and sufficiently large sterile drapes, thoroughly cleaning the skin prior to catheter insertion, allowing sufficient time for the disinfectant to exert its antibacterial action. Also during postoperative handling of the epidural catheter, aseptic technique is very important.
Specialized cells called oligodendrocytes lay down multiple layers of myelin around axons, the long “wires” that connect brain cells. Adult brains contain oligodendrocyte progenitor cells (OPCs), which are stem cells that generate myelin-producing cells. OCPs are found to multiply in the brains of individuals with multiple sclerosis as if to respond to myelin damage, but for unknown reasons they are not effective in restoring white matter. NINDS-funded scientists are studying cellular mechanisms that control the generation and maturation of OPCs to allow remyelination, which could be an effective therapy for transverse myelitis and spinal cord injury. Other NIND-funded investigators are focusing on mechanisms and interventions designed to increase oligodendrocyte proliferation and remyelination after spinal cord injury.