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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 68-70

Acute meningitis complicated by transverse myelitis: A rare complication


1 Department of Medicine, Hamad General Hospital, Hamd Medical Corporation; Weill Cornell Medical College, NY/Qatar
2 Department of Medicine, Hamad General Hospital, Hamd Medical Corporation, Qatar

Date of Web Publication24-Jun-2019

Correspondence Address:
Dr. Ijaz Kamal
Department of General Internal Medicine, Hamad General Hospital, PO Box. 3050, Doha

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2588-9044.261139

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  Abstract 

Acute meningitis can be complicated by intracranial complications commonly and rarely by spinal cord dysfunction. The causes of spinal cord dysfunction are cord compression, ischemic infarction of the cord, and acute myelitis. Magnetic resonance imaging (MRI) of the cord is the choice of investigation which not only helps to rule out any compressive lesion but will also confirm the diagnosis of myelitis. The usual findings of myelitis on MRI spine are the hyperintensities in T2-weighted images that predominantly involve the gray matter and usually extend from the cervical to the lumbar cord. Usually, patients are left with some residual deficits including spasticity, weakness, walking difficulties, and bowel–bladder dysfunction. We report a case of acute meningitis which was complicated by acute transverse myelitis.

Keywords: Acid-fast bacilli, acute transverse myelitis, cerebrospinal fluid, magnetic resonance imaging, meningitis


How to cite this article:
Kamal I, Minhas B, Eltahir RM, Elzouki AN. Acute meningitis complicated by transverse myelitis: A rare complication. Libyan J Med Sci 2019;3:68-70

How to cite this URL:
Kamal I, Minhas B, Eltahir RM, Elzouki AN. Acute meningitis complicated by transverse myelitis: A rare complication. Libyan J Med Sci [serial online] 2019 [cited 2019 Sep 19];3:68-70. Available from: http://www.ljmsonline.com/text.asp?2019/3/2/68/261139


  Introduction Top


Acute meningitis can be complicated by intracranial complications such as cerebrovascular accident, brain edema, hydrocephalus, or hearing impairment, as well as systemic complications, such as septic shock, adult respiratory distress syndrome, or disseminated intravascular coagulation.[1],[2] Spinal cord dysfunction is usually an infrequent complication which is more common in children but has been reported in adults as well.[3],[4] The causes can vary from cord compression to ischemic infarction of the cord and acute myelitis. Cord compression can be due to spinal abscess or hemorrhage following lumbar puncture, whereas cord infarction can be due to vasculitis, shock, herniation, or arachnoiditis. Acute transverse myelitis is a rare cause of myelopathy, with an incidence of 1 to 4 cases/million/year.[5],[6] We report a case of a 34-year-old gentleman with acute meningitis, who developed Acute transverse myelitis as a complication which was confirmed by magnetic resonance imaging (MRI) of the spine.


  Case Report Top


A 34-year-old man from India male presented with a 3-day history of headache, neck pain, and low back pain. He was previously healthy and had no medical history in the past. He is unmarried and is working as a technical engineer. He is a nonsmoker and nonalcoholic. This was followed by progressive weakness in both legs and unable to pass urine. Neurological examination revealed neck stiffness with paraparesis, with power of Grade 2 in both legs. It was associated with hypotonia and hyporeflexia in both lower limbs with equivocal planters. He had reduced sensation with sensory level at T10. He was admitted as a case of suspected meningitis with signs of spinal cord dysfunction and was started on antibiotics. An urgent cerebrospinal fluid (CSF) examination showed high white blood cell (WBC) of 4278 (90% neutrophils), high protein of 1.88 g/L, low glucose of 2.4 mmol/L (<50% of serum glucose), and Gram stain and culture of CSF were negative. The CSF viral panel, tuberculosis (TB) smears and cultures, and TB polymerase chain reaction were negative.

The power in the lower limbs worsened to zero in few hours of admission; therefore, an urgent MRI spine was done which demonstrated abnormal cervicodorsal signals from C7–D11, representing transverse myelitis [Figure 1]. MRI brain was normal. As the patient showed very slow recovery initially, he was started on steroid and antituberculous medication, but antituberculous medication was stopped after negative culture for TB. Repeated CSF analysis in a week time showed marked improvement with WBC count dropped to 77 (88% lymphocytes) and normalization of glucose and protein. MRI of the spine was repeated after 1 week which showed reduction of abnormal signal intensity. After initial stabilization, he was transferred to a rehabilitation center with tapering dose of steroids and 10 days of antibiotics.
Figure 1: Initial magnetic resonance imaging spine showing the hyperintensities on T2-weighted images that predominantly involve the gray matter

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The patient showed marked clinical improvement at the rehabilitation center after 6 weeks of presentation with increase in the power grade of 4/5 in bilateral lower limbs; however, his bladder and bowel control was still absent. Repeat MRI at 6 weeks showed complete resolution of abnormal findings seen before [Figure 2].
Figure 2: Repeat magnetic resonance imaging spine after 1 month showing complete resolution of the changes present on the initial magnetic resonance imaging spine

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  Discussion Top


Our case report is an example of a rare complication of acute meningitis in adults. The usual causes of spinal cord dysfunction in acute meningitis are compression by spinal abscess, epidural hemorrhage, and ischemic infarction of the cord due to vascular compromise.[1],[2] However, acute myelitis has been reported previously as a cause of cord dysfunction in patients with acute meningitis.[2],[3] Although it is more common in children, it has been reported in adults also.[4] The most frequent initial symptoms are motor symptoms such as quadriplegia or paraplegia, sensory symptoms, and bladder–bowel dysfunction.[3],[4] Spinal cord symptoms become evident from the time of diagnosis of meningitis and last for a variable time and even some patients are left with residual deficits.[5] The most common reported residual deficits are spasticity, weakness, walking difficulties, and bowel–bladder dysfunction. Our patient had slight residual weakness in the lower limbs with bladder and bowel dysfunction.[5]

The cord dysfunction is not related to the causative organism of meningitis as even it has been reported in those cases of meningitis where no organism was isolated.[5],[6],[7] In our case, no bacterial organism was isolated, and TB workup and viral screen were also negative. MRI of the spine is critical to evaluate patients with suspected cord dysfunction.[6],[7] MRI of the spine will help to exclude compression as well as to distinguish various types of transference myelitis, as the prognosis, risk of recurrence, and treatment options may differ among these distinct entities.[7],[8]

The nature and extent of spinal cord dysfunction associated with meningitis in adults was first described by Kastenbauer et al.[5] where the most common finding which was present on MRI T2-weighted images was hyperintensities predominantly involving the gray matter which extended from the cervical to lumbar cord. The MRI of the spine of our patient showed hyperintensities on T2-weighted images extending from C7 to T11 level. A literature review of patients aged 2 years or more with similar complications showed that young children have cervical cord lesions, whereas the majority of adolescents and adults have thoracic or lumbar lesions.[9],[10] Clinical follow-up of these patients suggests that myelitis during acute bacterial meningitis, has an unfavorable prognosis and all patients have some persistent neurologic deficits, regardless of age.[9],[10] Our patient showed significant improvement over a period of few weeks in terms of weakness and spasticity, but bladder and bowel incontinence persisted. A following MRI of the spine in our patient showed complete resolution of the hyperintensities.


  Conclusion Top


This case demonstrates that myelopathy is an infrequently reported complication of bacterial meningitis in adults that can occur due to vasculitis, infarction, autoimmune myelopathy, or direct infection of the spinal cord. The aim of presenting this case is to consider this complication in patients with meningitis who develop the symptoms of acute cord dysfunction.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Khan J, Altafullah I, Ishaq M. Spinal cord dysfunction complicating meningococcal meningitis. Postgrad Med J 1990;66:302-3.  Back to cited text no. 1
    
2.
Tal Y, Crichton JU, Dunn HG, Dolman CL. Spinal cord damage: A rare complication of purulent meningitis. Acta Paediatr Scand 1980;69:471-4.  Back to cited text no. 2
    
3.
Pfister HW, Feiden W, Einhäupl KM. Spectrum of complications during bacterial meningitis in adults. Results of a prospective clinical study. Arch Neurol 1993;50:575-81.  Back to cited text no. 3
    
4.
Seay AR. Spinal cord dysfunction complicating bacterial meningitis. Arch Neurol 1984;41:545-6.  Back to cited text no. 4
    
5.
Kastenbauer S, Winkler F, Fesl G, Schiel X, Ostermann H, Yousry TA, et al. Acute severe spinal cord dysfunction in bacterial meningitis in adults: MRI findings suggest extensive myelitis. Arch Neurol 2001;58:806-10.  Back to cited text no. 5
    
6.
Transverse Myelitis Consortium Working Group. Proposed diagnostic criteria and nosology of acute transverse myelitis. Neurology 2002;59:499-505.  Back to cited text no. 6
    
7.
Kaplin AI, Krishnan C, Deshpande DM, Pardo CA, Kerr DA. Diagnosis and management of acute myelopathies. Neurologist 2005;11:2-18.  Back to cited text no. 7
    
8.
Christensen PB, Wermuth L, Hinge HH, Bømers K. Clinical course and long-term prognosis of acute transverse myelopathy. Acta Neurol Scand 1990;81:431-5.  Back to cited text no. 8
    
9.
Pidcock FS, Krishnan C, Crawford TO, Salorio CF, Trovato M, Kerr DA, et al. Acute transverse myelitis in childhood: Center-based analysis of 47 cases. Neurology 2007;68:1474-80.  Back to cited text no. 9
    
10.
Defresne P, Hollenberg H, Husson B, Tabarki B, Landrieu P, Huault G, et al. Acute transverse myelitis in children: Clinical course and prognostic factors. J Child Neurol 2003;18:401-6.  Back to cited text no. 10
    


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