Transverse Myelitis in Children
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Direct answer
Transverse myelitis is an acute inflammatory injury of the spinal cord that causes symmetrical motor, sensory and bladder dysfunction below a clear sensory level. Its MRI shows a T2-bright cord lesion, often spanning three or more segments in children (longitudinally extensive), with no compressive cause. Management is pulse intravenous methylprednisolone, with plasma exchange for steroid-refractory disease and testing for aquaporin-4 and MOG antibodies.
What you must remember
- Clinical syndrome: limb weakness, a sensory level, and bladder or bowel dysfunction develop over hours to days, with upper motor neuron signs.
- MRI findings: a T2-hyperintense, typically central cord lesion, often longitudinally extensive (three or more contiguous segments) in children, sometimes enhancing with gadolinium; a normal early MRI does not exclude it.
- Cerebrospinal fluid: pleocytosis or raised protein is common, and oligoclonal bands point towards demyelinating disease.
- Triggers: Mycoplasma, varicella-zoster, enterovirus and EBV are classic infectious triggers, and post-vaccination cases have been reported.
- Antibodies: aquaporin-4 IgG (neuromyelitis optica spectrum) and MOG antibodies predict a different course and treatment.
- Differential: Guillain-Barre syndrome has ascending flaccid weakness, areflexia and no sensory level, with raised protein and normal cell count, while compression and cord infarction must also be excluded.
- Acute treatment: intravenous methylprednisolone at 30 mg/kg per day, maximum 1 g, for three to five days.
- Escalation: plasma exchange for poor response, and immunotherapy such as rituximab for aquaporin-4 disease.
A pathway from leg weakness to treatment
A 10-year-old develops leg weakness, a sensory band at the umbilicus and urinary retention over three days after a febrile illness. The steps below organise the workup.
- Recognise the cord syndrome: symmetrical weakness with upper motor neuron signs and a clear sensory level points to the spinal cord rather than the nerve roots.
- Exclude compression: urgent MRI of the whole spine rules out an epidural abscess, tumour or disc lesion, which need surgery rather than steroids.
- Image the brain: MRI of the brain looks for demyelinating lesions and helps distinguish acute disseminated encephalomyelitis from isolated transverse myelitis.
- Sample the CSF: lumbar puncture checks for pleocytosis, protein and oligoclonal bands, and PCR panels seek a viral or bacterial trigger.
- Test the antibodies: serum aquaporin-4 and MOG antibodies are sent, with autoimmune screening if systemic disease is suspected.
- Give pulse steroids: intravenous methylprednisolone is given for three to five days, with early rehabilitation referral.
- Escalate if needed: plasma exchange for a poor response, then long-term immunotherapy guided by antibody status.
Where the exam tries to catch you
Transverse myelitis is most often confused with Guillain-Barre syndrome, and the MRI and CSF pattern usually decides it.
- Trap: calling a child with a sensory level and bladder dysfunction Guillain-Barre syndrome. Correct: Guillain-Barre syndrome lacks a sensory level and bladder involvement is unusual, so upper motor neuron signs and a spinal lesion favour transverse myelitis.
- Trap: delaying steroids while waiting for antibody results. Correct: pulse steroids are started promptly once infection and compression are considered, because early treatment supports recovery.
- Trap: reading a normal early MRI as excluding transverse myelitis. Correct: early imaging can be normal, so repeat MRI is needed when the clinical syndrome stays typical.
Frequently asked questions
What MRI finding is typical of transverse myelitis?
Transverse myelitis typically shows a T2-hyperintense spinal cord lesion on MRI, often spanning three or more contiguous vertebral segments (longitudinally extensive) in children. The lesion is usually central, and gadolinium enhancement may or may not be present.
How does Guillain-Barre syndrome differ from transverse myelitis in children?
Guillain-Barre syndrome causes ascending flaccid weakness with areflexia and no sensory level, and CSF shows raised protein with a normal cell count. Transverse myelitis causes a sensory level, upper motor neuron signs and bladder dysfunction, with an abnormal spinal MRI.
What is the first-line treatment for acute transverse myelitis in children?
Intravenous methylprednisolone is the first-line treatment for acute transverse myelitis in children, commonly given at 30 mg/kg per day, up to 1 g, for three to five days. Plasma exchange is added for children who do not improve.
Why is a normal early MRI not enough to rule out transverse myelitis?
Spinal MRI may be normal in the first days of an acute cord syndrome, before inflammation produces visible signal change. Repeat imaging is therefore needed when clinical features remain typical.