Abstract
A 16-year-old girl with a history of clavicular chronic recurrent multifocal osteomyelitis (CRMO) presented with fever, vomiting, urinary and bowel retention, thigh paresthesia, and back pain for 2 days. The patient had 2 separate viral illnesses within a month prior to presentation. Spine magnetic resonance imaging (MRI) displayed increased T2 hyperintensity of the central grey matter from C3 to the conus medullaris (Figure 1). Findings were consistent with longitudinally extensive transverse myelitis. Cerebrospinal fluid analysis revealed elevated protein (51; reference range: <48 mg/dL), IgG index (.74; reference range <.70), and glucose (99; reference range 40-75 mg/dL). There was pleocytosis of 22 white blood cells (88% lymphocytes and 12% monocytes) with negative AQP4 and MOG antibodies. COVID-19 spike protein was positive with a negative PCR and non-immunized status, suggesting prior infection. Four months later, a pelvic MRI revealed new evidence of CRMO.
Keywords: autoimmune diseases of the nervous system, myelitis, transverse < autoimmune diseases of the nervous system, myelitis, transverse < autoimmune diseases of the nervous system, myelitis, transverse < transverse < spinal cord diseases, CRMO, Chronic Recurrent Multifocal Osteomyelitis
A 16-year-old girl with a history of clavicular chronic recurrent multifocal osteomyelitis (CRMO) presented with fever, vomiting, urinary and bowel retention, thigh paresthesia, and back pain for 2 days. The patient had 2 separate viral illnesses within a month prior to presentation. Spine magnetic resonance imaging (MRI) displayed increased T2 hyperintensity of the central grey matter from C3 to the conus medullaris (Figure 1). Findings were consistent with longitudinally extensive transverse myelitis. Cerebrospinal fluid analysis revealed elevated protein (51; reference range: <48 mg/dL), IgG index (.74; reference range <.70), and glucose (99; reference range 40-75 mg/dL). There was pleocytosis of 22 white blood cells (88% lymphocytes and 12% monocytes) with negative AQP4 and MOG antibodies. COVID-19 spike protein was positive with a negative PCR and non-immunized status, suggesting prior infection. Four months later, a pelvic MRI revealed new evidence of CRMO.
Figure 1.
T2 weighted MRI images indicate hyperintensity in the central grey matter from C3 to the conus. No enhancement was seen on imaging. A. Sagittal cervico-thoracic image at the level of C4/C5. B. Axial cervico-thoracic image at the level of C4/C5
Pediatric transverse myelitis (TM) is rare and often idiopathic. 1 Many have reported post-infectious TM after a COVID-19 infection, however there are no known associations between TM and CRMO. 2 CRMO is an inflammatory condition suggesting a theoretical connection, especially as TM can herald broader autoimmune diseases. 3
Many patients with TM report prodromal illness, motor and sensory symptoms, and sphincter dysfunction. Most children have longitudinally extensive lesions on imaging. 4 Our patient met the diagnostic criteria with bilateral sensory symptoms attributed to the spinal cord, pleocytosis, elevated IgG index, and consistent imaging. 3 Thirty percent of patients with idiopathic TM have a poor prognosis with gadolinium enhancement and female gender predicting morbidity. 1
Footnotes
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD
Natan Cramer https://orcid.org/0000-0001-5937-1461
References
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