Tuberculous myelitis
| Tuberculous myelitis | |
|---|---|
| Synonyms | Tuberculous transverse myelitis |
| Classification and external resources | |
| Specialty | Neurology, Infectious disease |
| Patient UK | Tuberculous myelitis |
Tuberculous myelitis is a form of Transverse myelitis caused by infection of the spinal cord by Mycobacterium tuberculosis. It is a rare but serious neurological complication of tuberculosis (TB), characterised by inflammation and damage to the spinal cord leading to neurological deficits.[1][2][3] Tuberculous myelitis may occur as a direct infection of the spinal cord or as a complication of Tuberculous meningitis or spinal tuberculosis (Pott disease).[2][4] The condition presents with symptoms such as Back pain, Muscle weakness, Paralysis, sensory loss, and bladder or bowel dysfunction.[5][1] Diagnosis is based on clinical presentation, MRI, and laboratory evidence of tuberculosis infection.[1][6][3] Treatment involves standard anti-tuberculosis drug regimens (such as Isoniazid, Rifampicin, Pyrazinamide, Ethambutol) combined with corticosteroids to reduce inflammation.[7][1] Prognosis varies depending on the severity and timeliness of treatment, with some patients recovering fully while others may suffer lasting neurological impairments.[1][6][3]
Signs and symptoms
Tuberculous myelitis typically presents with symptoms of spinal cord dysfunction that develop over hours to weeks. Common clinical features include:
- Back pain localised to the back or radiating along nerve roots
- Muscle weakness or Paralysis affecting the limbs below the lesion level
- sensory loss such as numbness, tingling or paraesthesia
- Bladder dysfunction and bowel dysfunction, including urinary retention or incontinence and constipation
- Possible Fever and constitutional symptoms related to active tuberculosis infection[5][1][3][8]
The neurological deficits usually correspond to the spinal cord segments involved and may be unilateral or bilateral.[1][2][9]
Causes
Tuberculous myelitis results from infection of the spinal cord by M. tuberculosis. The infection can reach the cord via haematogenous spread from a primary pulmonary or extrapulmonary focus or by direct extension from adjacent vertebral tuberculosis (Pott disease). It can also complicate Tuberculous meningitis.[2][1][4]
The pathogenesis involves an inflammatory response to the mycobacterial infection leading to oedema, Demyelination, and Necrosis of the spinal cord. This inflammation disrupts neural transmission and causes neurological deficits.[6][3]
Other infectious and non-infectious causes of Transverse myelitis include viral infections (e.g. herpesviruses, HIV, Enterovirus), bacterial infections (e.g. Lyme disease, Syphilis), autoimmune disorders (such as Multiple sclerosis), and idiopathic causes.[5][10][11]
Pathophysiology
Inflammation in tuberculous myelitis is characterised by infiltration of inflammatory cells, spinal cord oedema, and Demyelination, visible on MRI as hyperintense T2-weighted signals with cord enlargement.[1][3] Post-contrast MRI may show marginal enhancement of the affected segments.[9][6]
The immune response to M. tuberculosis within the cord leads to tissue damage and neurological impairment. The extent of damage depends on the severity of infection and host immune factors.[6][11]
Diagnosis
Diagnosis involves a combination of clinical evaluation, imaging findings and laboratory tests:
- Magnetic resonance imaging (MRI): Shows cord lesions with T2 hyperintensity, oedema and, occasionally, contrast enhancement. Lesions may be multifocal, most often in the cervicothoracic region.[1][9]
- CSF analysis: May reveal lymphocytic pleocytosis, elevated protein and low glucose, findings consistent with TB meningitis or spinal infection.[1][3]
- Microbiological tests: Acid-fast bacilli staining, culture and nucleic acid amplification tests (e.g. PCR, metagenomic NGS) on CSF or tissue confirm M. tuberculosis infection.[6][4]
- Chest imaging: Chest X-ray or CT scan may identify pulmonary tuberculosis as the source.[1][2]
The differential diagnosis includes other causes of Transverse myelitis such as Multiple sclerosis, viral myelitis, neurosyphilis and spinal cord infarction.[5][10][11]
Treatment
Management follows standard WHO-recommended anti-tuberculosis therapy, typically comprising Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol during an intensive phase followed by continuation phase therapy.[7][1][3]
Adjunctive corticosteroids are frequently used to reduce cord inflammation and oedema, potentially improving neurological outcomes.[1][3][11]
Supportive care includes physiotherapy to address motor deficits and measures to manage bladder and bowel dysfunction.[5][8]
Prognosis
Outcome is variable. Early diagnosis and prompt treatment improve prognosis: studies report that about 60 % of patients recover fully, 20 % have mild deficits and 20 % sustain severe permanent impairments.[1][3] Delayed therapy or extensive cord involvement is associated with worse outcomes.[6][4]
Epidemiology
Tuberculous myelitis is rare but more commonly encountered in regions with a high prevalence of tuberculosis. It can affect any age group but is more frequent among immunocompromised individuals or those with disseminated TB.[1][2][11]
See also
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 Gupta, R (16 March 2022). "Myelitis: A common complication of tuberculous meningitis". Frontiers in Neurology. 13 (5): 626–648. doi:10.1002/ca.23880. PMC 8965833 Check
|pmc=value (help). PMID 35396731 Check|pmid=value (help). - ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Jain, R. S. (2011). "Tuberculous myelitis: Clinical profile and outcome". Annals of Indian Academy of Neurology. 14 (1): 35–39. doi:10.1371/journal.pone.0018416. PMC 3081097. PMID 21541019.
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 Ravishankar, S (2017). "Tuberculous myelitis: A rare cause of acute transverse myelitis". Journal of Neurosciences in Rural Practice. 8 (1): 164–166. doi:10.4103/0976-3147.193555. PMC 5322754. PMID 28250567.
- ↑ 4.0 4.1 4.2 4.3 Omar, N (2023). "Tuberculous myelitis: A case series and review". Journal of Infection in Developing Countries. 17 (2): 267–273. doi:10.1111/rda.14339. PMID 36881512 Check
|pmid=value (help). Retrieved 3 June 2025. - ↑ 5.0 5.1 5.2 5.3 5.4 "Transverse myelitis – Symptoms & causes". Mayo Clinic. 19 January 2022. Retrieved 3 June 2025.
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Zhang, Y (2022). "Tuberculous myelitis: A prospective follow-up study". Journal of Neurology. 43 (9): 5615–5624. doi:10.1007/s10072-022-06221-6. PMC 9225802 Check
|pmc=value (help). PMID 35739331 Check|pmid=value (help). - ↑ 7.0 7.1 "Tuberculosis". World Health Organization. 10 October 2023. Retrieved 3 June 2025.
- ↑ 8.0 8.1 Kumar, V (2015). "Acute transverse myelitis: Clinical profile, etiology and predictors of outcome". Annals of Indian Academy of Neurology. 18 (4): 409–413. doi:10.4103/0972-2327.165468 (inactive 1 July 2025). PMC 4677229. PMID 26677476.
- ↑ 9.0 9.1 9.2 Zhou, Y (6 November 2021). "Concurrent tuberculous transverse myelitis and asymptomatic neurosyphilis: A case report". World Journal of Clinical Cases. 9 (31): 9645–9653. doi:10.12998/wjcc.v9.i31.9645. PMC 8610911 Check
|pmc=value (help). PMID 34867653 Check|pmid=value (help). - ↑ 10.0 10.1 "Transverse Myelitis (TM): Causes, Symptoms & Treatment". Cleveland Clinic. 19 March 2025. Retrieved 3 June 2025.
- ↑ 11.0 11.1 11.2 11.3 11.4 Beh, S. C. (February 2013). "Transverse myelitis". Neurologic Clinics. 31 (1): 79–138. doi:10.1016/j.ncl.2012.09.008. PMC 7132741 Check
|pmc=value (help). PMID 23186897.
External links
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