Transverse myelitis (TM) is a relatively infrequent but severe complication in systemic lupus erythematosus (SLE). Owing to its rarity and unfavorable outcome, we investigated its general features on MRI and incidence in the context of lupus activity, to facilitate early recognition and treatment.
Methods
We report a case of a young man with clinically inactive lupus nephritis but who presented with a sudden attack of myelitis. We performed systematic literature search in Medline to study the clinical features of SLE-related TM.
Results
From 1960 to April 2013, a total of 72 articles containing 194 cases of lupus myelitis were found. Among acquired articles, 93 patients fulfilled the inclusion criteria. The majority of the cases (88.8%) were female. Longitudinal myelitis was the predominant imaging finding on MRI (71.4%, 45/63). Nearly two-thirds (61/94) of lupus myelitis occurred in association with active lupus, and one-third (33/94) occurred in low disease activity.
Conclusions
Upon literature review, we found myelitis in SLE more frequently manifested as longitudinal on MRI. Although lupus myelitis often presented at an active phase of SLE, one-third of events happened in the presence of low disease activity. Early initiation of effective immunosuppressive therapy facilitated recovery.
WestSG. Neuropsychiatric lupus. Rheum Dis Clin North Am1994; 20: 129–158.
4.
BertsiasGKIoannidisJPAringerM. EULAR recommendations for the management of systemic lupus erythematosus with neuropsychiatric manifestations: Report of a task force of the EULAR standing committee for clinical affairs. Ann Rheum Dis2010; 69: 2074–2082.
ProvenzaleJMBarboriakDPGaenslerEHRobertsonRLMercerB. Lupus-related myelitis: Serial MR findings. AJNR Am J Neuroradiol1994; 15: 1911–1917.
7.
WeinshenkerBGWingerchukDMVukusicS. Neuromyelitis optica IgG predicts relapse after longitudinally extensive transverse myelitis. Ann Neurol2006; 59: 566–569.
8.
ScottTFFrohmanEMDe SezeJGronsethGSWeinshenkerBG. Evidence-based guideline: Clinical evaluation and treatment of transverse myelitis: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology2011; 77: 2128–2134.
9.
de SezeJStojkovicTBreteauG. Acute myelopathies: Clinical, laboratory and outcome profiles in 79 cases. Brain2001; 124: 1509–1521.
TanEMCohenASFriesJF. The 1982 revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum1982; 25: 1271–1277.
12.
Transverse Myelitis Consortium Working Group. Proposed diagnostic criteria and nosology of acute transverse myelitis. Neurology2002; 59: 499–505.
13.
BencivelliWVitaliCIsenbergDA. Disease activity in systemic lupus erythematosus: Report of the Consensus Study Group of the European Workshop for Rheumatology Research. III. Development of a computerised clinical chart and its application to the comparison of different indices of disease activity. The European Consensus Study Group for Disease Activity in SLE. Clin Exp Rheumatol1992; 10: 549–554.
14.
LiangMHSocherSALarsonMGSchurPH. Reliability and validity of six systems for the clinical assessment of disease activity in systemic lupus erythematosus. Arthritis Rheum1989; 32: 1107–1118.
15.
BirnbaumJPetriMThompsonRIzbudakIKerrD. Distinct subtypes of myelitis in systemic lupus erythematosus. Arthritis Rheum2009; 60: 3378–3387.
16.
KovacsBLaffertyTLBrentLHDeHoratiusRJ. Transverse myelopathy in systemic lupus erythematosus: An analysis of 14 cases and review of the literature. Ann Rheum Dis2000; 59: 120–124.
17.
LuXGuYWangYChenSYeS. Prognostic factors of lupus myelopathy. Lupus2008; 17: 323–328.
18.
DaiYJLiuQHeJLiZG. Myelopathy associated with systemic lupus erythematosus: A clinical analysis of 10 cases and review of literature [article in Chinese]. Zhong Hua Nei Ke Za Zhi2013; 53: 213–217.
19.
HarisdangkulVDoorenbosDSubramonySH. Lupus transverse myelopathy: Better outcome with early recognition and aggressive high-dose intravenous corticosteroid pulse treatment. J Neurol1995; 242: 326–331.
20.
Téllez-ZentenoJFRemes-TrocheJMNegrete-PulidoRODávila-MaldonadoL. Longitudinal myelitis associated with systemic lupus erythematosus: Clinical features and magnetic resonance imaging of six cases. Lupus2001; 10: 851–856.
21.
TanLFLiHLiangLQZhanZPLianF. Clinical analysis of 6 cases of systemic lupus erythematosus complicated by transverse myelitis [article in Chinese]. Nan Fang Yi Ke Da Xue Xue Bao2011; 31: 313–316.
22.
NiJGaoSWuQJCuiLY. Study on myelopathy associated with systemic lupus erythematosus in 6 cases. Zhong Guo Shen Jing Mian Yi Xue He Shen Jing Bing Xue Za Zhi2006; 13: 294–298.
23.
InslichtDVSteinABPomerantzFRagnarssonKT. Three women with lupus transverse myelitis: case reports and differential diagnosis. Arch Phys Med Rehabil1998; 79: 456–459.
24.
EspinosaGMendizábalAMínguezS. Transverse myelitis affecting more than 4 spinal segments associated with systemic lupus erythematosus: Clinical, immunological, and radiological characteristics of 22 patients. Semin Arthritis Rheum2010; 39: 246–256.
25.
MarabaniMZomaAHadleyDSturrockRD. Transverse myelitis occurring during pregnancy in a patient with systemic lupus erythematosus. Ann Rheum Dis1989; 48: 160–162.
Lopez DuplaMKhamashtaMASanchezADInglesFPUriolPLAguadoAG. Transverse myelitis as a first manifestation of systemic lupus erythematosus: A case report. Lupus1995; 4: 239–242.
28.
Neumann-AndersenGLindgrenS. Involvement of the entire spinal cord and medulla oblongata in acute catastrophic-onset transverse myelitis in SLE. Clin Rheumatol2000; 19: 156–160.
29.
YazawaSKawasakiSOhiT. Development of severe longitudinal atrophy of thoracic spinal cord following lupus-related myelitis. Intern Med2001; 40: 353–357.
30.
KimuraKYSeinoYHirayamaY. Systemic lupus erythematosus related transverse myelitis presenting longitudinal involvement of the spinal cord. Intern Med2002; 41: 156–160.
31.
VieiraJPOrtetOBarataDAbranchesMGomesJM. Lupus myelopathy in a child. Pediatr Neurol2002; 27: 303–306.
32.
ChenHCLaiJHJuanCJKuoSYChenCHChangDM. Longitudinal myelitis as an initial manifestation of systemic lupus erythematosus. Am J Med Sci2004; 327: 105–108.
33.
MoranneOHachullaEValatASSotoaresGPagniezDBoulangerE. Longitudinal myelitis in a pregnant patient with SLE. Am J Med2004; 116: 355–357.
34.
RadisCDCallisKP. Systemic lupus erythematosus with membranous glomerulonephritis and transverse myelitis associated with anabolic steroid use. Arthritis Rheum1997; 40: 1899–1902.
35.
RheuCWLeeSIYooWH. A catastrophic-onset longitudinal myelitis accompanied by bilateral internuclear ophthalmoplegia in a patient with systemic lupus erythematosus. J Korean Med Sci2005; 20: 1085–1088.
36.
dos SantosVMCorreia GarciaELeão RabeloFMenezes Haase LoboGESantos DamascenoMA. Transverse myelitis and chronic urticaria in systemic lupus erythematosus. Case report. Rev Med Chil2005; 133: 209–213.
HeinleinACGertnerE. Marked inflammation in catastrophic longitudinal myelitis associated with systemic lupus erythematosus. Lupus2007; 16: 823–826.
39.
MehtaLRSamuelssonMKKleinerAK. Neuromyelitis optica spectrum disorder in a patient with systemic lupus erythematosus and anti-phospholipid antibody syndrome. Mult Scler2008; 14: 425–427.
40.
NasirSKerrDABirnbaumJ. Nineteen episodes of recurrent myelitis in a woman with neuromyelitis optica and systemic lupus erythematosus. Arch Neurol2009; 66: 1160–1163.
41.
MulaMBolampertiLVarrasiC. SLE-related longitudinal myelitis with favorable outcome. Can J Neurol Sci2009; 36: 393–397.
42.
ZotosPPoularasJKarakitsosDKarabinisA. Lupus related longitudinal myelitis. J Rheumatol2010; 37: 1776–1776.
43.
Richard MornasAThomasTPallot PradesBChopinFRaouxD. Longitudinal myelitis in a patient with systemic lupus erythematosus. Joint Bone Spine2010; 77: 181–183.
44.
CampanaABuonuomoPSInsalacoA. Longitudinal myelitis in systemic lupus erythematosus: A paediatric case. Rheumatol Int2012; 32: 2587–2588.
45.
WhiteCLeonardBPatelA. Longitudinally extensive transverse myelitis: A catastrophic presentation of a flare-up of systemic lupus erythematosus. CMAJ2012; 184: E197–E200.
46.
KaplinAIKrishnanCDeshpandeDMPardoCAKerrDA. Diagnosis and management of acute myelopathies. Neurologist2005; 11: 2–18.
47.
JacobAWeinshenkerBG. An approach to the diagnosis of acute transverse myelitis. Semin Neurol2008; 28: 105–120.
48.
WingerchukDMLennonVALucchinettiCFPittockSJWeinshenkerBG. The spectrum of neuromyelitis optica. Lancet Neurol2007; 6: 805–815.
49.
AndrianakosAADuffyJSuzukiMSharpJT. Transverse myelopathy in systemic lupus erythematosus. Report of three cases and review of the literature. Ann Intern Med1975; 83: 616–624.
50.
DeodharAAHochenedelTBennettRM. Longitudinal involvement of the spinal cord in a patient with lupus related transverse myelitis. J Rheumatol1999; 26: 446–449.
51.
PawateSSriramS. Isolated longitudinal myelitis: A report of six cases. Spinal Cord2009; 47: 257–261.
52.
SchulzSWSheninMMehtaAKebedeAFluerantMDerkCT. Initial presentation of acute transverse myelitis in systemic lupus erythematosus: Demographics, diagnosis, management and comparison to idiopathic cases. Rheumatol Int2012; 32: 2623–2627.
53.
KampylafkaEIAlexopoulosHKosmidisML. Incidence and prevalence of major central nervous system involvement in systemic lupus erythematosus: A 3-year prospective study of 370 patients. PLoS One2013; 8: e55843–e55843.
54.
LavalleCPizarroSDrenkardCSánchez-GuerreroJAlarcón-SegoviaD. Transverse myelitis: A manifestation of systemic lupus erythematosus strongly associated with antiphospholipid antibodies. J Rheumatol1990; 17: 34–37.
55.
BoumpasDTPatronasNJDalakasMCHakimCAKlippelJHBalowJE. Acute transverse myelitis in systemic lupus erythematosus: Magnetic resonance imaging and review of the literature. J Rheumatol1990; 17: 89–92.
56.
GovoniMBombardieriSBortoluzziA. Factors and comorbidities associated with first neuropsychiatric event in systemic lupus erythematosus: Does a risk profile exist? A large multicentre retrospective cross-sectional study on 959 Italian patients. Rheumatology (Oxford)2012; 51: 157–168.
57.
KatsiariCGGiavriIMitsikostasDDYiannopoulouKGSfikakisPP. Acute transverse myelitis and antiphospholipid antibodies in lupus. No evidence for anticoagulation. Eur J Neurol2011; 18: 556–563.
