Introduction
Acute transverse myelitis is a rare spinal cord inflammatory disorder that manifests as sudden onset of motor weakness, sensory disturbance, and autonomic dysfunction. Here, we report a case of acute transverse myelitis in a 10-year-old boy secondary to upper respiratory infection which presented with right upper extremity weakness without sensory or autonomic changes. He was diagnosed with transverse myelitis based on his MRI findings, although his presentation was mainly asymmetric motor weakness, which is more consistent with acute flaccid paralysis.
Case report
A 10-year-old previously healthy boy visited the outpatient department of pediatrics in September 2018 with right arm motor weakness. This symptom has occurred 5 days after upper respiratory infection with a high fever. There was no sensory disturbance, bladder or bowel dysfunction, and visual disturbance. Muscle strength of right upper extremity was 2/5 grade in shoulder flexion, abduction, and extension, 2/5 grade in elbow flexion, 3/5 grade in wrist extension, finger flexion, and extension. He had normal strength of left upper extremity and both lower extremities. Reflexes were absent in right biceps and brachioradialis, but normal on the left side. Proprioception, pinprick, and light touch sensation tests were symmetrically intact. Initial magnetic resonance image (MRI) of the cervical spine showed ill-defined T2 high signal intensity in the level of C2 to C7, T3 to T7, T10 to T11(more markedly in cervical lesion) which can be interpreted as transverse myelitis (Fig. 1, Fig. 2). There was no abnormal finding in Brain MRI. Cerebral spinal fluid(CSF) analysis showed pleocytosis of 19/mm3 with 74% lymphocytes and 19% monocytes. Electrodiagnostic studies showed abnormal spontaneous activity on right deltoid, triceps, and decreased interference pattern on right biceps brachii, triceps, deltoid muscle. He was undergone upper extremity strengthening exercise, deltoid isometric exercise, hand ergometer, and neuromuscular electric stimulation. After 1 year from the onset, he currently had no restrictions on daily life and motor functions were recovered up to 4/5 grade on the right upper extremity.
Conclusion
We described a case of pediatric acute transverse myelitis with unusual clinical and radiological features. The patient presented with acute-onset asymmetric flaccid weakness without sensory or autonomic changes, which is suggestive of acute flaccid myelitis. In the clinical review of the United States, only 3(5%) of 56 acute flaccid myelitis patients reported complete recovery of strength, and 10(18%) reported being fully functional at a median of 4.2 months after onset. Children have a better outcome than adults with 50% of pediatric cases making a complete recovery by 2 years. There may be a good prognosis if the proper exercise program is carried out within these patients.
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