Acta Paediatr 01: 103-4. 1992
CASE REPORT
Transverse myelitis following mumps in children M Nussinovitch, N Brand', M Frydman and I Varsano Department of Pediatrics, Golda Medical Center, Husharon Hospital, Petach Tikoah. Israel; Department of Pediatrics, Sheba Medical Center, Tel Hashomer. Israel'
Nussinovitch M, Brand N, Frydman M , Varsano I. Transverse myelitis following mumps in children. Acta Paediatr I992;81: 183-4. Stockholm. ISSN 0803-5253 Although acute transverse myelitis is a rare complication of mumps, it is relatively well documented. We describe a child who developed mumps associated acute transverse myelitis and who subsequently recovered completely. To our knowledge, only 13 cases have been reported in children. This case is compared with 13 previously reported patients. 0 Mumps, transverse myelitis M Nussinovitch, Department of Pediatrics, Golda Medical Center, Hasharon Hospital, Petah- Tikvah 49372. Israel
Acute transverse myelitis is an acute intramedullary spinal cord disease characterized by an abrupt onset of rapidly progressive weakness of the lower extremities accompanied by a loss of sensation and sphincter control (1-2). An association with a large variety of infectious agents has been described. These include herpes, Epstein-Barr Virus (EBV), hepatitis B virus, influenza and various exanthematous diseases (2-4). Mumps was seldomly reported in association with transverse myelitis.
Case report A 7;-year-old boy presented with pain in both thighs, headache and fever. He was unable to walk and had urinary retention which required catheterization. He had no history of antecedent back injury, rash, toxin exposure or immunization. His brother had mumps three weeks previously. Physical examination on admission revealed an irritablechild with apathy and dehydration. His rectal temperature was 3 8 T , pulse 100 per minute and respiration 24 per minute. Blood pressure was 110/70 mmHg. Bilateral parotid swelling was present. The neck was supple, but Brudzinski's and Kerning's signs were positive. The heart sounds were normal with no audible murmurs. Neurological examination revealed weakness of the lower limbs, which were flaccid and arreflexic and full use of his arms with intact reflexes. The abdominal reflexes were diminished. His anal sphincter was patulous and he dribbled urine. Symmetrically impaired sensation to pin prick and touch was found below the dermatome TZ.The rest of the physical and neurological examination was normal. Laboratory .findings
WBC 15,600 cells/mm3( 1 5.6 x 109/1)(73% neutrophils), sedimentation rate 40 mm/h standard. SMA tests were
normal. Cerebrospinal fluid contained 685 leukocytes/ mm3 (685 x lo6 cells/l) (81Yo were lymphocytes, 4% segmented neutrophils and 15% monocytes). Protein was 70 mg/dl and glucose 60 mg/dl. Blood and cerebrospinal fluid viral and bacterial cultures were sterile. Cerebrospinal fluid myelin basic protein was 127 ng/ml (normal < 7 ng/ml). Cerebrospinal antibodies for mumps rose from 1/60 on admission to 1/480, three weeks later. Serological tests for: herpes, Epstein-Bar Virus, influenza, Respiratory Syncytial Virus, enterovirus were negative. EEG revealed a diffuse moderating slowing of background activity. C T of brain and the entire spine was normal. The child was treated with intravenous fluids, steroids, urocholine and catheterization. Four days after admission he began to move his lower legs, but a right abducent paresis appeared and resolved seven days later. He was able to walk within two weeks. At a follow-up examination six weeks later, reduced tone in the lower limbs was still present but subsequently he had a full neurological recovery.
Discussion Acute transverse myelitis is more common in adults and is rare in children. About two-thirds of affected children have a history of a recent or concurrent acute infection. The cause of the condition is obscure, but a cellmediated autoimmune response has been suggested. This concept is supported by the observation that lymphocytes from 70% of transverse myelitis patients responded to human peripheral nerve myelin PI protein ( 1-2). Alternatively, direct viral-induced lesion may be suggested in view of the short time interval and recovery in pari-passu with antibody increment. Clinically, salivary gland involvement followed by central nervous
184
M Nussinooiich
ACTA PRDIATR 81 (1992)
Tuhle 1. Reported cases of transverse myelitis following mumps in children.
CFS findings Authors Scheid (9)
R o p w (8) Paine (2) Benady ( 10) Thomas (1 1) Present case Total
Case No.
Sex
F F M F F M M F F M M F F M 8-F 6-M
1
2 3 4 5 6 7 8 9 10
I1 12 13 14 14
Range (mean)
Age (years) 16 6 16 15 15 13 12 17 8 5 3 10 4 7.5
3-17 (10.5)
Days following *mumps
Motor and sensory level
14
Cells
Protein (mg"/.)
Recovery time months
200 N.M. N.M. 300 37 57 N.M. N.M.
6 24 4
14 60 7 5 N.M. 7
4 220 10 300 100 227 52 N.M. 90 N.M. 27 90 625 68 5
N.M. 35 15 25 70
5-60 (1 5)
4-685 (210)
15-300 (92)
10
21 14 10 20 9 10
+
**
10
2 1
**
8
1-24 (5)
~~
* First day of parotid swelling; * N.M.-not mentioned; ** Died.
system abnormalities is the most common presentation ( 6 ) and has been reported in Over 65% Of Patients with mumps (7). Our patient had prominent signs of men-
References
with CNS involvement with mumps. Transversemyelitis has rarely been reported in association with mumps, and the few reports (2-4, 8-1 1) are summarized in Table 1. The syndrome is characterized by weakness of the lower extremities and most patients have bladder and bowel disturbances (l3/14). Most patients suffered from motor and sensory disturbances at the thoracic level. Only three patients were treated with steroids. There is no convincing evidence that steroids or any other form of therapy has any significant effect on the outcome of the illness (2, 8). Nevertheless, most authors recommend steroidal therapy. The prognosis of acute transverse myelitis in children following mumps as summarized seems to be quite good. Ten of fourteen patients have a good return to function, two patients died and two suffered from fixed paralysis. The prognosis is better in children than in adults.
5. Tyler KL. Gross RA, Cascino GD. Unusual viral causes of transverse myelitis: hepatitis A virus and cytomegalovirus. Neurology 1986;36:855-8 6. Levitt LP, Rich TA, Kinds SW. et al. Central nervous system mumps. Neurology 1970;20:829-34 7. Ritter BS. Mumps meningoencephalitis in children. J Pediatr 1958;52:424-33 8. Ropper AH, Poskanzer DC. The prognosis of acute and subacute transverse myelopathy based on early signs and symptoms. Ann Neurol 1978;4:51-9 9. Scheid W. Mumps virus and the central nervous system. World Neurol 1961;2:1l7-30 10. Benady S, Ben Zvi A, Szabo G . Transverse myelitis following mumps. Acta Paediatr Scand 1973:62:205-6 1 I . Thomas FB, Perkins RL, Saslaw S. Paralytic mumps infection in two sisters. Arch Intern Med 1968;121:45-9
I . Artrocchi PH. Acute transverse myelopathy. Arch Neurol 1963~9:1I1-19
CASE REPORT
Transverse myelitis following mumps in children M Nussinovitch, N Brand', M Frydman and I Varsano Department of Pediatrics, Golda Medical Center, Husharon Hospital, Petach Tikoah. Israel; Department of Pediatrics, Sheba Medical Center, Tel Hashomer. Israel'
Nussinovitch M, Brand N, Frydman M , Varsano I. Transverse myelitis following mumps in children. Acta Paediatr I992;81: 183-4. Stockholm. ISSN 0803-5253 Although acute transverse myelitis is a rare complication of mumps, it is relatively well documented. We describe a child who developed mumps associated acute transverse myelitis and who subsequently recovered completely. To our knowledge, only 13 cases have been reported in children. This case is compared with 13 previously reported patients. 0 Mumps, transverse myelitis M Nussinovitch, Department of Pediatrics, Golda Medical Center, Hasharon Hospital, Petah- Tikvah 49372. Israel
Acute transverse myelitis is an acute intramedullary spinal cord disease characterized by an abrupt onset of rapidly progressive weakness of the lower extremities accompanied by a loss of sensation and sphincter control (1-2). An association with a large variety of infectious agents has been described. These include herpes, Epstein-Barr Virus (EBV), hepatitis B virus, influenza and various exanthematous diseases (2-4). Mumps was seldomly reported in association with transverse myelitis.
Case report A 7;-year-old boy presented with pain in both thighs, headache and fever. He was unable to walk and had urinary retention which required catheterization. He had no history of antecedent back injury, rash, toxin exposure or immunization. His brother had mumps three weeks previously. Physical examination on admission revealed an irritablechild with apathy and dehydration. His rectal temperature was 3 8 T , pulse 100 per minute and respiration 24 per minute. Blood pressure was 110/70 mmHg. Bilateral parotid swelling was present. The neck was supple, but Brudzinski's and Kerning's signs were positive. The heart sounds were normal with no audible murmurs. Neurological examination revealed weakness of the lower limbs, which were flaccid and arreflexic and full use of his arms with intact reflexes. The abdominal reflexes were diminished. His anal sphincter was patulous and he dribbled urine. Symmetrically impaired sensation to pin prick and touch was found below the dermatome TZ.The rest of the physical and neurological examination was normal. Laboratory .findings
WBC 15,600 cells/mm3( 1 5.6 x 109/1)(73% neutrophils), sedimentation rate 40 mm/h standard. SMA tests were
normal. Cerebrospinal fluid contained 685 leukocytes/ mm3 (685 x lo6 cells/l) (81Yo were lymphocytes, 4% segmented neutrophils and 15% monocytes). Protein was 70 mg/dl and glucose 60 mg/dl. Blood and cerebrospinal fluid viral and bacterial cultures were sterile. Cerebrospinal fluid myelin basic protein was 127 ng/ml (normal < 7 ng/ml). Cerebrospinal antibodies for mumps rose from 1/60 on admission to 1/480, three weeks later. Serological tests for: herpes, Epstein-Bar Virus, influenza, Respiratory Syncytial Virus, enterovirus were negative. EEG revealed a diffuse moderating slowing of background activity. C T of brain and the entire spine was normal. The child was treated with intravenous fluids, steroids, urocholine and catheterization. Four days after admission he began to move his lower legs, but a right abducent paresis appeared and resolved seven days later. He was able to walk within two weeks. At a follow-up examination six weeks later, reduced tone in the lower limbs was still present but subsequently he had a full neurological recovery.
Discussion Acute transverse myelitis is more common in adults and is rare in children. About two-thirds of affected children have a history of a recent or concurrent acute infection. The cause of the condition is obscure, but a cellmediated autoimmune response has been suggested. This concept is supported by the observation that lymphocytes from 70% of transverse myelitis patients responded to human peripheral nerve myelin PI protein ( 1-2). Alternatively, direct viral-induced lesion may be suggested in view of the short time interval and recovery in pari-passu with antibody increment. Clinically, salivary gland involvement followed by central nervous
184
M Nussinooiich
ACTA PRDIATR 81 (1992)
Tuhle 1. Reported cases of transverse myelitis following mumps in children.
CFS findings Authors Scheid (9)
R o p w (8) Paine (2) Benady ( 10) Thomas (1 1) Present case Total
Case No.
Sex
F F M F F M M F F M M F F M 8-F 6-M
1
2 3 4 5 6 7 8 9 10
I1 12 13 14 14
Range (mean)
Age (years) 16 6 16 15 15 13 12 17 8 5 3 10 4 7.5
3-17 (10.5)
Days following *mumps
Motor and sensory level
14
Cells
Protein (mg"/.)
Recovery time months
200 N.M. N.M. 300 37 57 N.M. N.M.
6 24 4
14 60 7 5 N.M. 7
4 220 10 300 100 227 52 N.M. 90 N.M. 27 90 625 68 5
N.M. 35 15 25 70
5-60 (1 5)
4-685 (210)
15-300 (92)
10
21 14 10 20 9 10
+
**
10
2 1
**
8
1-24 (5)
~~
* First day of parotid swelling; * N.M.-not mentioned; ** Died.
system abnormalities is the most common presentation ( 6 ) and has been reported in Over 65% Of Patients with mumps (7). Our patient had prominent signs of men-
References
with CNS involvement with mumps. Transversemyelitis has rarely been reported in association with mumps, and the few reports (2-4, 8-1 1) are summarized in Table 1. The syndrome is characterized by weakness of the lower extremities and most patients have bladder and bowel disturbances (l3/14). Most patients suffered from motor and sensory disturbances at the thoracic level. Only three patients were treated with steroids. There is no convincing evidence that steroids or any other form of therapy has any significant effect on the outcome of the illness (2, 8). Nevertheless, most authors recommend steroidal therapy. The prognosis of acute transverse myelitis in children following mumps as summarized seems to be quite good. Ten of fourteen patients have a good return to function, two patients died and two suffered from fixed paralysis. The prognosis is better in children than in adults.
5. Tyler KL. Gross RA, Cascino GD. Unusual viral causes of transverse myelitis: hepatitis A virus and cytomegalovirus. Neurology 1986;36:855-8 6. Levitt LP, Rich TA, Kinds SW. et al. Central nervous system mumps. Neurology 1970;20:829-34 7. Ritter BS. Mumps meningoencephalitis in children. J Pediatr 1958;52:424-33 8. Ropper AH, Poskanzer DC. The prognosis of acute and subacute transverse myelopathy based on early signs and symptoms. Ann Neurol 1978;4:51-9 9. Scheid W. Mumps virus and the central nervous system. World Neurol 1961;2:1l7-30 10. Benady S, Ben Zvi A, Szabo G . Transverse myelitis following mumps. Acta Paediatr Scand 1973:62:205-6 1 I . Thomas FB, Perkins RL, Saslaw S. Paralytic mumps infection in two sisters. Arch Intern Med 1968;121:45-9
I . Artrocchi PH. Acute transverse myelopathy. Arch Neurol 1963~9:1I1-19
