Predictors of Recurrence Following an Initial Episode of Transverse Myelitis

Kimbrough et al. published a study in 2014 about characteristics that predict recurrence following an acute transverse myelitis event. Because transverse myelitis can occur in several diseases such as multiple sclerosis and neuromyelitis optica (NMO), it is important to distinguish patients with relapsing disease from those with monophasic (one time event) transverse myelitis in order to treat appropriately and reduce the chances of long-term disability. The authors conducted a retrospective study of 192 patients who were referred to the Johns Hopkins Transverse Myelitis Center from 2005 to 2012. These patients were characterized as either having monophasic TM (no relapses after 3 years) or recurrent TM. Those with recurrent TM were categorized into three groups: recurrent myelitis in the spinal cord without a known cause, NMO or NMO Spectrum Disorder, or an autoimmune rheumatologic disease.

All 192 patients were initially diagnosed with monophasic TM. Of those, 82 (42.7%) patients maintained their diagnosis of monophasic idiopathic TM, while 110 (57.3%) patients were eventually diagnosed with recurrent diseases, including 69 patients with NMO/NMOSD, 34 patients with recurrent TM, and 7 patients with autoimmune rheumatologic disease. Of those with NMO/NMOSD, 24 of the 69 cases (35%) had NMO and tested positive for NMO IgG, 7 (10%) cases had NMO but were NMO IgG negative, and 38 (55%) cases were diagnosed as NMOSD. The recurrent group was more likely to be female and African American, with women almost twice as likely to develop recurrent disease than men. This increased risk is largely because these groups are more likely to develop NMO or NMOSD. Those with longitudinally extensive transverse myelitis (LETM, or a lesion extending more than three vertebral segments) were more likely to have recurrent myelitis and NMO/NMOSD, although LETM also occurred in patients with monophasic disease and non-NMO recurrent TM. Increased white blood cell count in the cerebrospinal fluid, positive IgG (Immunoglobulin G) index, presence of oligoclonal bands in the CSF, vitamin D insufficiency and deficiency, presence of antinuclear antibodies (ANA) greater than or equal to 1:160, and presence of Ro/SSA antibodies were also associated with recurrent disease.

The authors also note that it is unclear whether to treat patients with combinations of risk factors using immunosuppression without knowing for sure if they have recurrent TM, as there have not been clinical trials conducted about this. They suggest closely monitoring patients with idiopathic TM for the first 6-12 months after diagnosis and repeatedly testing for NMO IgG, ANA, and Ro/SSA antibodies.