Acute transverse myelitis in psoriatic arthritis

Abstract

Acute transverse myelitis (ATM) is an isolated inflammatory spinal cord dysfunction with many distinct aetiologies [8]. Psoriatic arthritis is an inflammatory arthritis, usually seronegative for rheumatoid factor, associated with psoriasis. ATM is associated with systemic inflammatory diseases, like systemic lupus erythematosus, rheumatoid arthritis and Sjogren’s disease, but not with psoriatic arthritis. To our knowledge, this is the first report of ATM associated with psoriatic arthritis. A 50-year old woman presented to our hospital with a 1-day history of rapidly ascending asymmetrical paraesthesias, progressive painless weakness of the legs and urgeincontinence. She was known with psoriatic arthritis for 8 years with an undulating course of psoriasis, arthritis especially of the distal interphalangeal joints, dactylitis, and enthesitis of the pelvic bones, demanding continuous treatment with 20 mg oral methotrexate a week for 8 years. Three weeks before admission she had a severe mono-arthritis of her right ankle, treated with a high dose (60 mg a day initially) of prednisone. At presentation in our hospital, neurological examination revealed a paresis of both legs (MRC grade 4 of the right, grade 1 of the left leg), a Babinski’s sign on the left side, and a sensory level at T10. Visual acuity of both eyes was normal. Magnetic resonance imaging (MRI) of the spine on the day of admission showed no abnormalities. Cerebrospinal fluid (CSF) white cell count, protein, glucose and IgG index were normal. Oligoclonal bands were not present in the CSF. Blood examination showed a normal erythrocyte sedimentation rate and leukocyte count. Rheumatoid factor was\20.0 IU/mL. Antinuclear antibody (ANA) and extractable nuclear antigens (ENA) screening were negative. Serum antiphospholipid, anticyclic citrullinated peptide (CCP) and antiaquaporin 4 antibodies were not present. Serological and polymerase chain reaction (PCR) tests excluded recent or active infection with Epstein–Barr virus, herpes simplex virus, varicella zoster virus, Lyme disease, syphilis, enterovirus, parechovirus, Mycoplasma pneumoniae, Coxiella burnetii and Chlamydia psittaci. A cerebral MRI-scan showed no abnormalities. A second MRI-scan of the spine, made 3 days after admission, showed a T2 hyperintense lesion of the central spinal cord from vertebral level T10 to the conus medullaris, without enhancement after gadolinium (Fig. 1). Leg weakness progressed to almost complete paralysis 3 days following onset of symptoms. Treatment with intravenous methylprednisolone was started and a gradual amelioration followed. The many different aetiologies of ATM prompt physicians to do an extensive diagnostic workup in a patient presenting with ATM. First, several infectious agents can be causative [8]. This was considered in our patient particularly as she used immunosuppressive agents, but an infection could not be shown in the CSF or serum. Second, ATM can be the presenting feature of multiple sclerosis [7]. Brain MRI and CSF did not support this diagnosis in our patient. Third, a longitudinally extensive transverse myelitis (i.e. more than three vertebral segments) can be an initial manifestation or a limited form of neuromyelitis J. J. G. Rath (&) P. W. Wirtz Department of Neurology, Haga Hospital, Leyweg 275, 2545 CH The Hague, The Netherlands e-mail: jjgrath@hotmail.com