464 - Regression During Rehabilitation Reveals Atypical Presentation of Transverse Myelitis

Case Diagnosis: Atypical Transverse Myelitis

Case Description: A 42-year-old female with history of excised thoracic hemangioblastoma and stable syrinx initially presented with progressive lower extremity weakness, sensory impairment, urinary retention, and bowel incontinence after recent viral illness. Lumbar puncture, EMG, and MRI were unremarkable. She was diagnosed with Guillain Barre Syndrome, given IVIG and steroids, and admitted to inpatient rehabilitation. Admission examination revealed antigravity strength in lower extremities, stocking distribution sensory loss, and diffuse hyperreflexia in all extremities. Despite treatment she declined neurologically, developing complete lower extremity flaccid paralysis. Repeat MRI showed interval development of bilateral cervical and thoracic cord T2 hyperintensity concerning for transverse myelitis. Extensive infectious, inflammatory, autoimmune, and paraneoplastic workup was initiated by the rehabilitation team, and neurology was consulted. The patient was readmitted for plasmapheresis. Upon returning to inpatient rehabilitation, she demonstrated neurological and functional improvement. She discharged mostly independent in a wheelchair, requiring occasional minimum assistance for complex activities of daily living.

Discussions: Transverse myelitis and Guillain Barre Syndrome are immune-mediated processes that may be difficult to distinguish during initial history and workup. Previous literature described a Guillain Barre/Transverse Myelitis Overlap Syndrome and MRI-negative transverse myelitis. This patient’s recent viral illness, progressive ascending weakness, and initial absence of MRI findings led to the initial diagnosis of Guillain Barre Syndrome. Baseline hyperreflexia made distinguishing primary upper motor neuron and lower motor neuron processes difficult. While T2 hyperintensity on MRI is a classic feature of transverse myelitis, it may not appear until later as seen in this case.

Conclusions: This case highlights an occurrence of an atypical presentation of transverse myelitis, initially presenting similarly to Guillain Barre Syndrome, following a recent viral illness. The case underscores the key role of the physiatrist in expanding differential diagnoses and potentially escalating care when neurologic findings do not correspond with the anticipated trajectory of recovery.