Coexistence of myositis, transverse myelitis, and Guillain Barré syndrome following Mycoplasma pneumoniae infection in an adolescent
A 14-year-old female patient was admitted with numbness and weakness of the legs and the arms. She had 9 days history of back pain with gradual weakness and paresthesia of the arms. Weakness progressed to involve all extremities and ultimately she was unable to stand and sit. Ten days prior to the onset of her symptoms, she had upper respiratory tract infection. She had received no medications during the course of infection. Based on the clinical findings, a presumptive diagnosis of myositis was made at an outside institution because of high serum creatine kinase level (2190 U/L, normal 29–168). She had no history of intramuscular injection. The patient was referred to our institution for further investigation. There was no history of consanguinity and neurologic disease in the family. Physical and neurological examination revealed normal deep tendon reflexes. There were no pathological reflexes. Muscle strengths in proximal and distal muscles of upper and lower extremities were 3/5 and 4/5, respectively. She had no sensory level and there was no lateralizing neurologic deficit. She had no bladder and bowel dysfunction. Abdominal skin reflexes were normal. The remainder of the physical and neurological examination was normal.\nLaboratory examinations including blood count, renal, and liver function analyses, C-reactive protein, revealed no abnormality. Erythrocyte sedimentation rate was 28 mm/h (normal 0–20). Magnetic resonance imaging of brain was normal. Spine magnetic resonance imaging revealed hyperintense punctate lesions in the anterior cervicothoracic spinal cord, extending from C4 to T3 vertebral level on T2 weighted series. These lesions were enhancing on post-contrast series, which is consistent with disrupted spinal cord-blood barier []. Initial motor conduction studies on the 10th day of illness revealed a decrease in motor response amplitudes in bilateral median nerves and the left common peroneal nerve. The F response latency of bilateral tibial nerves was prolonged. Upper and lower extremity sensory responses were normal. The right median nerve conduction velocity was slow. The electromyography findings were consistent with mild acute motor polyneuropathy.\nNeurologic, radiologic, and electromyographic findings suggested myositis, transverse myelitis, and GBS. Examination of the cerebrospinal fluid revealed normal protein and glucose levels with no pleocytosis. Cerebrospinal fluid polymerase chain reaction (PCR) was negative for adenovirus, varicella zoster virus, herpes simplex virus, and enterovirus. Cerebrospinal fluid culture showed no growth of any bacteria. Examination of cerebrospinal fluid revealed a normal IgG index (0.7; normal values 0.3–0.7). Isoelectrofocusing was negative for oligoclonal bands. Anti-nuclear antibodies and anti-double stranded deoxyribonucleic acid antibodies were negative. Complement levels (C3, C4) were normal. Serological work-up for toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus, ebstein barr virus, brucella, salmonella, and hepatitis were negative. Serum M. pneumoniae IgM and IgG (85 RU/mL) were positive indicating an acute infection. M. pneumoniae serology was repeated 1 week after admission and showed an increase in M. pneumoniae IgG (148 RU/mL) titer. The case was considered as myositis, transverse myelitis, and GBS caused by M. pneumoniae infection.\nThe patient was treated with intravenous immunoglobulin (1 g/kg/day for 2 days) and clarithromycin (15 mg/kg/day). Clarithromycin was continued for 2 weeks. The patient′s complaints disappeared and strength improved over the following weeks.\nOn the 14th day of treatment, spinal magnetic resonance imaging demonstrated minimal regression in hyperintense signals. Repeated motor conduction studies revealed increase in motor response amplitudes. On 15th day of the follow-up, muscle strength was 4–5/5 in bilateral proximal upper and lower extremities. Her strength was 5/5 in the distal upper and lower extremities. She was discharged after starting to walk independently.