Enteroviral Transverse Myelitis Presenting as Acute Ataxia in Children: A Case Series

Abstract

Background: Enteroviruses, members of the Picornaviridae family, typically cause asymptomatic or mild infections. However, they can also result in central nervous system (CNS) involvement, with transverse myelitis (TM) occurring only on rare occasions. TM is a syndrome characterized by acute or subacute spinal cord dysfunction, leading to neurological deficits below the level of the lesion. Case report: We report a case series of eight pediatric patients admitted over a three-month period, June to August 2024. All patients presented with ataxia and/or other neurological symptoms, alongside abnormal cerebrospinal fluid (CSF) findings. Although ataxia is commonly associated with cerebellitis, magnetic resonance imaging (MRI) in this cohort revealed findings consistent with TM. Notably, all patients demonstrated similar MRI abnormalities. The onset of symptoms occurred over a short time during an enterovirus epidemic. Enteroviral RNA was detected, or the virus was isolated in seven patients, while one patient had a close epidemiological link to the virus. All patients achieved full recovery following immunomodulatory therapy. Conclusions: This case series underscores that ataxia may be an atypical symptom associated with TM. Furthermore, there was a notable distinction between the clinical presentation and neuroradiological findings. Immunomodulatory therapy with immunoglobulins and corticosteroids has been shown to be effective and safe, supporting the hypothesis of an immune-mediated pathogenesis in these patients.

Keywords: ataxia; enterovirus; infections; myelitis transverse; pediatrics.

Figure 1

Magnetic resonance imaging (MRI) findings in patients. Axial (a) and sagittal (c) T2-weighted MRI of Patient 2, axial T2-weighted MRI of Patient 3 (b), and sagittal T2-weighted MRI of Patient 6 (e) show high-intensity signals suggestive of myelitis (white arrow). Follow-up images of Patient 2 (d) and Patient 6 (f) reveal normal findings. All other patients had similar findings.