Myelitis and peripheral neuropathy

Syndrome/disease Organism Symptoms, signs, and neurologic findings CNS PNS Cord Other findings Risk factors
Anterior polio myelitis syndrome Poliovirus 1, 2, 3 Onset: Acute
Clinical patterns:
Spinal and bulbar paralysis
Common features:
Asymmetric flaccid paralysis (AFP)
“Minor illness” (3–4 d) influenza-like syndrome
“Major illness” (5–7 d) aseptic meningitis, myeloencephalitis
Absence of protective immunity and travel in endemic areas
Coxsackie A, B
West Nile virus (WNV)
Onset: Acute
Clinical patterns:
Similar to polio but milder disease
Asymptomatic infection: Common except at extremes of age and in immunosuppressed
CNS phase aseptic meningitis, encephalitis, encephalomyelitis Seasonal incidence in temperate climates (summer), year-round in tropical climates
WNV: Vector borne (mosquito) and transmitted by breast milk, blood transfusions, and organ transplants
Ascending myelitis syndrome (leukomyelitis) HIV-1 Onset: Acute/subacute
Clinical patterns:
See below
HTLV-1 Onset: Subacute/chronic
Clinical patterns: tropical spastic paraparesis (TSP) or HAM
“Rosette cells” in CSF lymphocytes
Coinfection with HIV in IVDUs
Injecting drug use
Prior residence in endemic areas
Onset: Acute
Clinical patterns:
Ascending pattern w/initial plexitis
Asymmetric commonly
Primarily seen in immunosuppressed Related to epidemiology of primary infection
Herpes B virus (Monkey B) Onset: Subacute (5–30 d)
Clinical pattern:
Aseptic meningitis
Ascending encephalomyelitis
Prodromal illness:
Early (vesicles);
Intermediate (numbness, weakness, hiccups)
Macaque monkey bite or exposure to tissues
Laboratory workers exposed to contaminated cell cultures
Transverse myelitis syndrome Primary myelitis
Onset: Acute (after prodrome)
Clinical patterns:
Sensory motor level
Initial spinal shock
Hyperreflexia below level of lesion
Related to epidemiology of primary infection
Secondary myelitis:
Bacteria, fungi, mycobacteria
Onset: Acute/subacute
Clinical patterns:
Radicular-spinal cord syndrome
Cauda equina syndrome
Related to primary infection and organisms Injecting drug use
Hematogenous osteomyelitis
Back surgery: Intraoperative contamination
Acute demyelinating encephalomyelitis (ADEM) Mycoplasma, Lyme, Enteroviruses, EBV, CMV, VZV, dengue, measles, hepatitis A, Semple Rabies vaccine Onset: Acute
Clinical patterns: Pyramidal and extrapyramidal symptoms, hemiplegia, ataxia, cranial neuropathies, myelitis paresthesias, polyradiculopathy, altered mental status
Related to epidemiology of primary infection

a Spirochetes include: Borrelia species (B. burgdorferi – Lyme, B. recurrentis – relapsing fever), Leptospira spp., Treponema pallidum.

Abbreviations: CMV = cytomegalovirus; CNS = central nervous system; CSF = cerebrospinal fluid; EBV = Epstein–Barr virus; HAM = HTLV-1-associated myelopathy; HIV = human immunodeficiency virus; HSV = herpes simplex virus; HTLV = human T-cell lymphotropic virus; IDUs = injecting drug users; IVDU = intravenous drug use; PNS = parasympathetic nervous system; VZV = varicella-zoster virus; WNV = West Nile virus.

Table 79.2 Peripheral neuropathy

Syndrome/disease Organism/ antibiotic Symptoms, signs, and neurologic findings CNS PNS Cord Other findings Risk factors
Acute (AIDP)
Chronic (CIDP)
1. Idiopathic
2. Infection-associated
Onset: Acute/subacute and chronic
Common features:
Progressive, symmetric weakness
Distalproximal limbs
Truncalcranial muscles
Paresthesias, hypotonia, areflexia
Clinical patterns:
Ascending, descending, bulbar
Variable autonomic dysfunction (ileus, cardiac) Preceding viral illness or vaccination, prior episode
Viral (EBV, HIV, dengue, hepatitis) Bacterial (Campylobacter)
Chlamydia (C. psittaci)
Mycoplasma (M. pneumoniae)
Spirochetes (Lyme borreliosis)
Neuropathy due to bacterial toxins Corynebacterium diphtheriae Onset: Acute/subacute
Clinical patterns:
Bulbar symptoms
Ascending peripheral neuropathy
Pharyngitis with pseudomembrane
Absence of protective immunity, epidemic respiratory diphtheria, contaminated wound
Clostridium botulinum Onset: Acute/subacute (dose-related)
Clinical patterns:
Bulbar symptoms
Myasthenia-like weakness
Autonomic dysfunction (dry tongue, ileus, urinary retention)
Decreased vital capacity
Food sources
Contaminated wounds (IDUs)
Sinusitis in cocaine snorters
Clostridium tetani Onset: Acute/subacute (dose-related)
Clinical patterns:
Localized, cephalic, generalized
Autonomic dysfunction
Hypertensive crises
Decreased vital capacity
Absence or loss of protective immunity
Puncture/contaminated wounds
Infected neonatal cord stumps
Onset: Acute (concentration-related)
Clinical patterns:
Neuromuscular blockade
Decreased vital capacity
Generalized paralysis
Excessive or unadjusted dosage for lean body mass
Isoniazid ddI, ddC, d4T
Onset: Subacute (dose and duration)
Clinical patterns:
Distal paresthesias and weakness
Progressive loss of distal DTRs
Isoniazid: Lack of pyridoxine
Nucleoside antiretrovirals:
Pre-existing neuropathy
Excessive or unadjusted dosage
Antibiotics: Cumulative dosage
Vasculitis Polyarteritis nodosa (PAN)
Onset: Subacute
Clinical patterns:
Mononeuritis multiplex
Common features:
Asymmetric weakness, paresthesias, loss of DTRs in affected areas
PAN: Asymptomatic micro-aneurysms
Wegener’s: sinusitis, pulmonary and renal lesions, +/– eosinophilia
PAN: Chronic active hepatitis B
Wegener’s: Unknown etiology
Leprosy Mycobacterium leprae Onset: Insidious/acute Clinical patterns:
Mononeuritis multiplex
Common features:
Anesthetic lesions, enlarged nerves
Nerves most commonly affected: Median, ulnar, peroneal
Genetic susceptibility
Prior residence in endemic areas
Reversal reaction

Abbreviations: AIDP = acute inflammatory demyelinating polyneuropathy; CIDP = chronic inflammatory demyelinating polyneuropathy; CNS = central nervous system; DTRs = deep tendon reflexes; EBV = Epstein–Barr virus; HIV = human immunodeficiency virus; IDUs = injecting drug users; PNS = peripheral nervous system.

Table 79.3 Polymorphic neurologic syndromes associated with infections

Syndrome/disease Organism Symptoms, signs, and neurologic findings CNS PNS Cord Other findings Risk factors
HIV-associated HIV-1 Onset: Acute, subacute, and chronic
Clinical patterns:
Acute: GBS, Bell’s palsy, mononeuritis multiplex
Subacute/chronic: Vacuolar myelopathy: progressive spasticity; Ascending myelitis (leukomyelitis); Sensory peripheral neuropathy (CIDP)
Acute infection: aseptic meningitis, infectious mononucleosis syndrome
Late disease: concurrent HIV encephalopathy
IVDU, sexual transmission, exposure to contaminated blood or body fluids
Dengue-associated Dengue virus Onset: acute or postinfectious
Clinical patterns: Myelitis (transverse), Guillain–Barré syndrome, mono- or poly-neuropathy, brachial neuritis, ADEM, encephalitis
Fever, headache, myalgia, arthralgia, rash, headache, leukopenia, thrombocytopenia, elevated liver transaminases Mosquito exposure in endemic region
Mycoplasma-associated Mycoplasma pneumoniae Onset: acute
Clinical patterns: Ascending myelitis (leukomyelitis), polyradiculitis
Commonly associated with encephalitis Recent upper respiratory infection in child or young adult
Neuro-brucellosis Brucella spp. Onset: Subacute/chronic
Clinical patterns:
Radiculitis, myelitis, CNS palsies
Encephalitis, meningitis, mycotic aneurysm; Leukoclastic vasculitis, thrombocytopenia and splenomegaly in children Unpasteurized milk products, occupational exposure to livestock and cattle parturition
Neuro-borreliosis Borrelia burgdorferi Onset: Acute and chronic
Clinical patterns:
Acute: Bell’s palsy, aseptic meningitis, encephalitis, transverse myelitis
Chronic: weakness, paresthesias
Acute: Erythema chronicum migrans Tick-bite
Travel or residence in endemic areas
Neurosyphilis Treponema pallidum Onset: Acute and chronic
Clinical patterns:
Acute syphilitic meningitis
Chronic asymptomatic
Chronic symptomatic (meningovascular, behavioral, tabes dorsalis, myelopathy)
Gumma (cord/meninges)
Uveitis, optic atrophy
Asymptomatic (abnormal CSF) and symptomatic neurosyphilis occurs after early syphilis. Higher risk with HIV infection with or without standard treatment of primary syphilis
Tuberculosis Mycobacterium tuberculosis Clinical patterns: Meningitis, vasculitis, cord infarction, granulomatous myeloradiculitis, intramedullary tuberculoma, cord compression from vertebral collapse Pulmonary disease, meningitis, fever Travel to or residence in high prevalence region, homelessness, incarceration, institutionalization, contacts with known tuberculosis
Schistosomiasis Schistosoma spp. Clinical patterns: Transverse myelitis, subacute myeloradiculopathy, encephalitis Fever, abdominal pain, hepatosplenomegaly Travel to or residence in endemic region
VZV-associated VZV Onset: Acute
Clinical patterns: Bell’s palsy, Ramsey Hunt syndrome
Sensory radiculitis (CNS and PNS)
Ascending and transverse myelitis
Dermatomal vesicles
Encephalitis Uveitis, corneal ulcer
Immunosuppression (with recrudescent VZV)
Herpes simplex-associated HSV Onset: Acute and recurrent
Clinical patterns: HSV-1: Bell’s palsy; HSV-2: sacral radiculitis (Elsberg syndrome)
Ascending necrotizing myelitis
Mollaret’s meningitis
Primary genital HSV

Abbreviations: ADEM = acute demyelinating encephalomyelitis; CNS = central nervous system; CSF = cerebrospinal fluid; HSV = herpes simplex virus; HIV = human immunodeficiency virus; PNS = peripheral nervous system; VZV = varicella-zoster virus; IVDU = intravenous drug use; GBS = Guillain–Barré syndrome; CIDP = chronic inflammatory demyelinating polyneuropathy.

Table 79.4 Etiology of neuropathic syndromes in HIV infection

Acute inflammatory demyelinating polyneuropathy (AIDP – Guillain–Barré syndrome)
Chronic inflammatory demyelinating polyneuropathy (CIDP)
Bell’s palsy
Ataxic dorsal radiculopathy
Mononeuritis multiplex from hepatitis B virus (HBV)-associated cryoglobulinemia
Opportunistic infections
Cryptococcal meningitis: bulbar palsies
Herpesviruses polyradiculopathy, sacral radiculitis, Bell’s palsy

Epstein–Barr virus

Cytomegalovirus (CMV)

Varicella-zoster virus (VZV)

Herpes simplex type 1 (HSV-1) type 2 (HSV-2)

Neurosyphilis: polyradiculopathy
Tuberculous meningitis: bulbar palsies
Drug toxicity or nutritional
Antiretroviral nucleoside analogs

Dideoxycytosine (ddC)

Dideoxyinosine (ddI)

Stavudine (d4T)

Niacin analog: isoniazid (INH) without B6
Neurotoxic antibiotics: aminoglycosides, chloramphenicol, metronidazole, nitrofurantoin, polymyxins
Vitamin deficiencies: folate, pyridoxine, B12

Figure 79.1 Algorithm for clinical and laboratory evaluation of acute myelitis and peripheral neuropathy.
Abbreviations: CSF = cerebrospinal fluid; CT = computed tomography; EMG = electromyogram; MRI = magnetic resonance imaging; PCR = polymerase chain reaction; WB = Western blot.


Myelitis refers to inflammation of the spinal cord. Myelitis may be infectious or noninfectious and primary – directly attacking cord structures – or secondary – adjacent processes altering cord function. Primary myelitis can present as one of three discrete clinical patterns: (1) anterior poliomyelitis, (2) leukomyelitis, or (3) transverse myelitis. Poliomyelitis is inflammation involving gray matter; leukomyelitis is confined to white matter. Transverse myelitis, inflammation of an entire cross section of the spinal cord, can affect more than one spinal segment. A number of infectious agents are known to cause or to be associated with myelitis. Myelitis can also occur after infection or vaccination as in the acute disseminated encephalomyelitis (ADEM) syndrome.

There are five cardinal manifestations of spinal cord disease: pain; motor deficits; sensory deficits; abnormalities of reflexes and muscle tone; and bladder dysfunction. The distribution of neurologic deficits depends on the spinal segment(s) affected. Local pain occurs at the site of the lesion and can assume a radicular quality if the nerve roots are involved. Paresthesias have greater localizing value than radicular pain. Weakness is present in virtually all spinal cord disorders, and in myelitis may progress over hours, days, or weeks. Spinal shock is characterized by absent plantar reflexes, and areflexia and atonia below the level of the lesion. More slowly progressive lesions are associated with hyperreflexia and hypertonia. Bladder dysfunction is usually not an early sign of spinal cord disease, although if spinal shock develops, flaccid bladder paralysis ensues with urinary retention and overflow incontinence. Chronic myelopathies cause a spastic bladder and result in urgency, frequency, and incontinence.

Acute primary infectious transverse myelitis must be distinguished from infectious secondary myelopathies and other noninfectious causes of myelitis such as multiple sclerosis or systemic lupus erythematosus. Magnetic resonance imaging (MRI) of the spinal cord must be performed early to exclude a compressive lesion.

Tropical spastic paraparesis/HTLV-1-associated myelopathy

Human T-cell lymphotropic virus type 1 (HTLV-1) is a retrovirus associated with adult T-cell leukemia/lymphoma and HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). Approximately 15 to 20 million people are infected worldwide with endemic areas in the Caribbean, southern Japan, Africa, and Italy. Among first time US blood donors, the prevalence in 2009 was 5 per 10 000,

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Jun 18, 2016 | Posted by in INFECTIOUS DISEASE | Comments Off on Myelitis and peripheral neuropathy

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