Mycoplasma pneumoniaeassociated transverse myelitis presenting as asymmetric flaccid paralysis

Salloum, Shafee; Goenka, Ajay; Ey, Elizabeth

Extensive CSF studies were performed including antibodies for arboviral encephalitis (West Nile, St. Louis, California, Eastern Equine, and Western Equine), polymerase chain reaction (PCR) for herpes simplex virus and enterovirus, Lyme antibodies, and oligoclonal bands. All were negative. His nasopharyngeal swab was also negative by PCR for adenovirus, enterovirus/rhinovirus, human metapneumovirus, parainfluenza, influenza, respiratory syncytial virus, coronavirus, Chlamydia pneumoniae, and Mycoplasma pneumoniae. Serum aquaporin 4 receptor antibody, antinuclear antibody, and antidouble strand DNA were negative as well. Stool viral culture was negative as well as rectal swab for enterovirus by PCR. His CSF M. pneumoniae antibodies were elevated; IgG 2.31 U/L and IgM 2.08 U/L. Reference ranges are: less than 0.09 and 0.76, respectively. A three-day course of high dose intravenous methylprednisolone (30 mg/kg/day) was started, followed by plasmapheresis due to lack of improvement on steroids, in addition to doxycycline (to treat his Mycoplasma infection). The patient was monitored closely in the intensive care unit. His respiratory status remained stable and he did not require ventilatory support. He did not develop any signs of autonomic instability such as bradycardia or hypertension. He had no urinary retention or constipation. He was fed initially through nasogastric tube due to development of dysphagia. Video fluoroscopic swallowing function study was performed a week after admission to the hospital and showed no tracheal aspiration.