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Título

Unusual etiology of transverse myelitis: Case report.

RESUMO

CASE REPORT: L.S.M., male, 18 YO, was admitted to a hospital with bilateral paresthesia in the plantar regions, ascending to the lower limbs, associated with sphincter incontinence, in June 2021. The brain MRI showed focci of high-signal on T2/ FLAIR, in the subcortical white matter, variable in size and shape, some with gadolinium enhancement; the cervical spine MRI showed nonspecific focal areas of high-signal on T2. The cerebro spinal fluid (CSF) was clear, with 04 cells mm³ (10% polymorphonuclear, 90% mononuclear); negative bacterioscopy, glucose 64 mg/dl; protein 28.4 mg/dl; negative culture. Blood VDRL was 1/32. He was treated with benzathine penicillin for 3 weeks and pulse therapy with methylprednisolone for 5 days, with no improvement in the symptoms. He was seen in our Service, in July 2021, and new tests were requested that showed VDRL 1/32; Vitamin B12 241, HIV negative, HTLV negative, Hepatitis B and C negative. A new CSF study on 07/27/21 showed 6 cels/mm3, 29 protein mg/dl, 80 lymphocytes, glucose 66 mg/dl, VDRL negative, FTAabs IgG positive, IgM negative, Kappa index 3.7 (normal < 2.9), OCB negative, anti-NMO negative, anti-MOG negative. He was treated with crystalline penicillin for 14 days and pulse therapy again for 5 days with significant improvement of the symptoms. In October, a new VDRL test was performed: 1/16. DISCUSSION: Syphilis is a sexually transmitted disease caused by the Treponema pallidum. It affects 12 million people a year worldwide. If untreated, the disease can progress up to the tertiary form, which affects the central nervous system (CNS) and can be presented from its different clinical types: meningovascular, general paresis and tabes dorsalis. Transverse myelitis has different etiologies, such as autoimmune diseases, CNS infections, hypovitaminosis B12 and demyelinating diseases Syphilitic myelitis is a form of meningo-vascular syphilis confined to the spinal cord. The diagnosis sometimes is challenging and comprises not only blood tests, but also MRI findings, such as “the flip-flop sign” or “the candle guttering appearance sign” and CSF test. MRI can sometimes be essential for a correct diagnosis. CONCLUSION: This case describes an uncommon presentation of syphilis as a transverse myelitis. Syphilis is a differential diagnosis to look after in transverse myelitis cases specially because of good clinical response to the therapy.

Palavras Chave

Transverse myelitis, syphilis, the candle guttering appearance sign”, “the flip-flop sign”.