Tuberculosis-Associated Longitudinally Extensive Transverse Myelitis

BACKGROUND Longitudinally extensive transverse myelitis (LETM) involves a continuous inflammatory lesion that spans 3 or more spinal segments. It is a recognized but rare manifestation of Mycobacterium tuberculosis infection. CASE REPORT A 51-year-old man originally from Mexico with a significant past medical history presented with altered mental status. He had a 1-year history of a chronic non-productive cough and approximately 20 days of fevers and headaches. Upon admission, he was encephalopathic without neurological deficits, and his Glasgow Coma Scale score was 11. A non-contrast computed tomography (CT) scan of the head was initially negative for pathology. Shortly after admission, he developed respiratory distress and worsening mental status, ultimately requiring intubation. A repeat non-contrast CT scan showed concern for hydrocephalus. An external ventricular drain was inserted into the right lateral ventricle, and cerebrospinal fluid (CSF) samples obtained from the drain were unremarkable. The patient underwent bronchoscopy with bronchoalveolar lavage, and the samples sent for Mycobacterium tuberculosis polymerase chain reaction testing were positive. He remained unresponsive. Magnetic resonance imaging (MRI) of the brain and spine was negative for obstruction but revealed diffuse leptomeningeal enhancement across multiple areas, consistent with extensive inflammatory longitudinal transverse myelitis, possibly secondary to pulmonary Mycobacterium tuberculosis infection. Ultimately, the CSF was negative for autoimmune or paraneoplastic processes but showed elevated inflammatory markers. He was treated with high-dose glucocorticoids, plasmapheresis, and anti-tuberculosis therapy. He remained intubated with only moderate improvement and was discharged after 2 months. CONCLUSIONS Tuberculous-associated LETM should be considered in patients with active pulmonary tuberculosis who develop a concomitant inflammatory myelopathy.