Tan W
Lim CT
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Dengue-related Longitudinally Extensive Transverse Myelitis
Wendy Tan1, Christopher Thiam Seong Lim2
1 Department of Medicine, Serdang Hospital, Malaysia
2 Unit of Nephrology, Department of Medicine, Universiti Putra Malaysia, Malaysia
Dr. Christopher Thiam Seong Lim
Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang - 43400
Tan W, Lim CT. Dengue-related Longitudinally Extensive Transverse Myelitis. Neurol India 2019;67:1116-7
Tan W, Lim CT. Dengue-related Longitudinally Extensive Transverse Myelitis. Neurol India [serial online] 2019 [cited 2021 Jan 19];67:1116-7. Available from: https://www.neurologyindia.com/text.asp?2019/67/4/1116/266296
A 21-year-old previously healthy gentleman presented with acute onset of fever and vomiting for approximately five days. His blood parameters were suggestive of dengue fever; he was discharged from the emergency department after hydration. Subsequently, he returned to the emergency department 2 days later with acute onset of urinary retention and paraparesis. His blood investigations are detailed in [Table 1]. A neurological examination was conducted which revealed examination revealed weakness over bilateral lower limb grade 3/5 and upper limb grade 4/5, with normal tone. Babinski sign was equivocal. A sensory loss was not loss was not documented. He was intubated due to a drop in Glasgow Coma Scale to 4/15, and was transferred to the intensive care unit (ICU). A compute topography scan of the brain was normal.
Table 1: Investigation
The patient was given was given intravenous methylprednisolone 500 mg OD for 3 days followed by a tapering dose of dexamethasone for 1 week. Neurological examination after 1 week in ICU, where he remained intubated and ventilated, revealed that he had become quadriplegic with sensory loss from C2 level. Magnetic resonance imaging (MRI) scan interpretation as per [Figure 1]. He made no neurological recovery and succumbed due to ventilator-acquired pneumonia after 28 days in the ICU.
Figure 1: MRI spine shows long-segment, contiguous, centrally located high T2-weighted images signal changes of the spinal cord at cervical (C3 to C7) and thoracic level (T8 to T10) suggestive of TM
Cases of longitudinally extensive transverse myelitis (LETM) associated with dengue are rare with a total of 6 adult cases reported worldwide.[1],[2],[3],[4] Nearly half of the 6 cases underwent MRI of the spine that showed an extensive skipped lesion in the cervical and thoracic region, which were similar in our patient. The first line of treatment was pulse methylprednisolone for three-five days while only one of them used intravenous immunoglobulin G (IVIG) alone for five days.[2] Regarding recovery, nearly all cases required intensive rehabilitation to regain muscle power. Some patients recovered as early as one week with 6 out of seven achieving full neurological recovery within six months while one of them had permanent neurological deficit despite treatment (intravenous methylprednisolone (MTP) for five days followed by IVIG for another 5 days).[1] Though rare, dengue-associated LETM could be fatal, and high index of suspicion is needed in dengue endemic region.
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[Table 1]