Case Presentation: A 46-year-old female with a history of amphetamine abuse, depression, and hypertension presented to the ED for acute onset of bilateral lower extremity weakness and urinary incontinence. She denied other associated symptoms. The patient’s neurologic exam was notable for symmetrically decreased lower extremities motor strength and reflexes to 2/5, decreased sensation below L1, and overflow incontinence. Imaging studies including the brain, thoracic, and lumbar MRI with and without contrast did not show any significant abnormalities. Lumbar puncture did not show any abnormal findings except protein of 146 mg/ml (normal 12-60) and Myelin basic protein of CSF was greater than 150 (0.0-3.7). All the microbiologic studies including Lyme, VDRL, VZV DNA, West Nile, Cryptococcus, HSV, TB PCR, gram stain, and cultures including Tuberculosis (AFB) were negative. Viral serology for hepatitis B, C, HIV, and COVID 19 was negative. A urine drug screen was positive for amphetamine. Vasculitis workup including Sjogren (anti-SSA and SSB), Rheumatoid arthritis, systemic lupus erythematosus, and lupus anticoagulant was negative. There were no oligoclonal bands in CSF, and serum protein electrophoresis was within the normal limit. Vitamins deficiency including vitamin B1,6,12 and heavy metal toxicity was ruled out. Serum ceruloplasmin and the copper level were within normal limits. ESR was 80 mm/hr. EMG of Lower extremities did not show any large fiber acute demyelinating neuropathy or acute denervation. She was started on IV immunoglobulin (IVIG), steroid therapy( methylprednisone 1 gram per day for 5 days), and plasmapheresis. She remarkably improved with the treatment. We continued conservative and supportive measures for her till complete recovery.
Discussion: Acute transverse myelitis is an acute inflammation of gray and white matter in one or more adjacent spinal cord segments. It happens mostly due to multiple sclerosis(MS) but it can happen in patients with vasculitis, systemic lupus erythematosus, viral and bacterial infections (meningoencephalitis), autoimmune or post-infectious inflammation like Lyme, mycoplasma, syphilis, tuberculosis, or in patients who are taking amphetamines, IV heroin, antifungal or antiparasitic medications. Diagnosis is done by MRI, cerebrospinal fluid (CSF) analysis, and blood tests. We present a case of transverse myelitis due to amphetamine toxicity.
Conclusions: Transverse myelitis is a rare neurologic condition which recognized with focal inflammation and injury of spinal cord. There are variety of medical conditions including infectious or non-infectious can cause it. This case report emphasis the importance of non-infectious cause of transverse myelitis and showed early diagnosis and treatment can be crucial in the patient recovery.