Longitudinally extensive transverse myelitis with pulmonary tuberculosis

Rationale: Longitudinally extensive transverse myelitis (LETM) is characterized by contiguous inflammatory lesions of spinal cord extending to ≥3 vertebral segments. The etiology of LETM is complicated, including various infection, autoimmune disease, and so on. Neuromyelitis optic spectrum disorder (NMOSD) is the most common cause of LETM. Several case reports have suggested the associations between NMOSD and pulmonary tuberculosis (PTB). Patient concerns: Patient 1, a 20-year-old woman who had a past history of PTB, presented with weakness, numbness, and pain in the limbs. The serum anti-aquaporin-4 antibody (AQP4-Ab) was strongly positive, and the magnetic resonance imaging (MRI) scan of cervical and thoracic spinal cord after admission to the hospital revealed hyperintensity lesions extending from C3 to T8 on T2-weighted (T2W) image, T1-weighted (T1W) image, and fluid-attenuated inversion recovery (FLAIR) image. Patient 2, a 21-year-old womanwho had a past medical history of PTBwithout receiving any treatment, presented for numbness in bilateral lower limbs and in the chest. The anti-AQP4-Ab was negative both in the serum and in the cerebral spinal fluid (CSF) of the patient. The MRI scan during hospitalization of cervical and thoracic spinal cord revealed diffuse hyperintense signal extending C3 to T11 on T2W and FLAIR images and hypointense signal on T1W image. Diagnosis: The first patient was diagnosed with anti-AQP4-Ab positive NMOSD, while the second case was an anti-AQP4-Ab negative LETM patient. Interventions: Both of the patients received a combination of corticosteroid and anti-tuberculosis (isonicotinyl hydrazide 0.3g/d, rifampin 0.45g/d, pyrazinamide 1g/d, and ethambutol 1g/d) treatment. Outcomes: The patients were followed up for up to 1 year. The Expanded Disability Status Scale (EDSS) of both patients were decreased and the lesion size in the spinal cord was significantly reduced at the time point of the follow-up. Lessons:Combination of anti-tuberculosis and corticosteroid treatment may have better prognosis for patient of LETM with PTB. Abbreviations: AQP4-Ab = aquaporin-4 antibody, BBB = blood–brain barrier, BCG = Bacillus Calmette-Guerin, CNS = central nervous system, CSF = cerebral spinal fluid, CT = computed tomography, DWI = diffusion-weighted imaging, EDSS = Expanded Disability Status Scale, ESR = erythrocyte sedimentation rate, FLAIR = fluid-attenuated inversion recovery, Ig = immunoglobulin, LETM = longitudinally extensive transverse myelitis, MBP =myelin basic protein, MOG =myelin oligodendrocyte glycoprotein, MRC = Medical Research Council, MRI = magnetic resonance imaging, NMOSD = neuromyelitis optic spectrum disorder, PTB = pulmonary tuberculosis, T1W = T1-weighted, T2W = T2-weighted, TB = tuberculosis.