Transverse Myelitis: An Inflammation of the Spinal Cord

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After years of investigation, I find myself returning to a fundamental question: Is there a pathophysiological link between cerebrospinal fluid (CSF) dynamics and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)?

Despite a growing body of literature, a definitive connection remains elusive. I have reviewed numerous studies in search of correlations between CSF abnormalities and the complex symptomatology of ME/CFS. While an increasing number of symptomatic treatments continue to emerge, much of the research still centers on clinical presentation rather than exploring underlying mechanisms—particularly chronic neuroinflammation, axonal demyelination, and their potential progression to disorders such as transverse myelitis.

Without comprehensive diagnostic evaluation—including MRI, PET imaging, and CSF analysis via lumbar puncture—targeting midbrain structures, white matter pathology, and neuronal damage, we risk missing critical insights into disease etiology.
A deeper investigation into central nervous system involvement in ME/CFS is imperative if we are to move beyond symptomatic care toward true disease-modifying therapies.

What is Transverse Myelitis?

Transverse myelitis (TM) is a rare neurological disorder involving inflammation of the spinal cord. This inflammation can damage or destroy myelin, the protective sheath that surrounds nerve fibers, disrupting communication between the brain and the rest of the body. The term "transverse" refers to the pattern of inflammation, which typically affects both sides of a specific segment of the spinal cord.

As a result, TM can cause a wide range of symptoms, including sensory changes (such as numbness or tingling), motor weakness, and dysfunction of autonomic processes like bladder, bowel, and sexual function. The onset may be sudden or develop over hours to days, and it can affect individuals of any age, gender, or background.

Causes of Transverse Myelitis

Although many cases of transverse myelitis are idiopathic—with no identifiable underlying cause—there are several known triggers. These causes are generally grouped into the following categories:

  1. Autoimmune Diseases

  2. Post-Infectious Immune Responses

  3. Direct Infections

  4. Paraneoplastic Syndromes

  5. Vaccination-Associated Cases

  6. Other Inflammatory or Vascular Conditions

Each of these categories contributes to inflammation in the spinal cord through different mechanisms, ranging from direct infection to misguided immune responses. A thorough clinical workup is often necessary to determine the specific cause and guide appropriate treatment.

1. Autoimmune Diseases

Autoimmune conditions are among the most common identifiable causes of TM. In these disorders, the immune system mistakenly attacks healthy tissue—in this case, the spinal cord.

  • Multiple Sclerosis (MS): TM may be the first manifestation or a recurring symptom of MS, a chronic disease that targets the central nervous system.

  • Neuromyelitis Optica Spectrum Disorder (NMOSD): Often associated with severe, longitudinally extensive TM, NMOSD is linked to antibodies against aquaporin-4 (AQP4).

  • Myelin Oligodendrocyte Glycoprotein Antibody Disease (MOGAD): A distinct autoimmune disorder characterized by the presence of anti-MOG antibodies, which can cause TM.

  • Systemic Lupus Erythematosus (SLE), Sjögren’s Syndrome, and Sarcoidosis: These systemic autoimmune diseases can also lead to spinal cord inflammation in rare cases.

2. Post-Infectious (Parainfectious) Inflammatory Responses

TM can occur as an immune-mediated response following an infection. The body’s immune system, in trying to eliminate an infectious agent, may inadvertently target spinal cord tissue.

  • This post-infectious form of TM may arise days or weeks after an infection has resolved.

  • It is more commonly seen in children but can occur at any age.

3. Direct Infections of the Spinal Cord

In some cases, TM is caused by direct infection of the spinal cord tissue by a pathogen.

  • Viruses:

    • Herpesviruses (e.g., HSV-1, HSV-2, VZV)

    • West Nile virus

    • Cytomegalovirus (CMV)

    • Epstein-Barr virus (EBV)

    • Enteroviruses

    • Human Immunodeficiency Virus (HIV)

  • Bacteria:

    • Lyme disease (Borrelia burgdorferi)

    • Syphilis (Treponema pallidum)

    • Tuberculosis (Mycobacterium tuberculosis)

  • Fungi and Parasites:

    • Though rare, fungal infections (e.g., Candida, Cryptococcus) and parasitic infections (e.g., Toxoplasma, Schistosoma) have been implicated in TM, particularly in immunocompromised individuals.

4. Paraneoplastic Syndromes

Paraneoplastic transverse myelitis is a rare complication that arises when the immune system reacts to a tumor elsewhere in the body, producing antibodies that mistakenly target spinal cord components.

  • These syndromes are most often associated with cancers such as lung, breast, or ovarian cancer.

  • Detection of specific onconeural antibodies may aid diagnosis.

5. Vaccination-Associated TM

Very rarely, transverse myelitis has been reported following certain vaccinations. This is thought to be due to an abnormal autoimmune response, not a direct effect of the vaccine itself.

  • The overall risk remains extremely low, and vaccines continue to be a critical tool in preventing infectious diseases.

  • Reported associations include vaccines for influenza, hepatitis B, and others.

6. Other Inflammatory or Vascular Conditions

  • Vascular disorders, such as spinal cord infarction (stroke), can mimic or contribute to TM.

  • Idiopathic cases remain, where no cause can be definitively identified even after comprehensive evaluation.

Symptoms

The onset of symptoms can be sudden, developing over a few hours to several days, or more gradually over several weeks. Symptoms depend on the level of the spinal cord affected and the extent of inflammation.

  • Motor symptoms: These include muscle weakness, which may progress to partial or complete paralysis of the limbs.

  • Sensory symptoms: Patients often report numbness, tingling, burning, or loss of sensation, typically below the level of inflammation.

  • Autonomic dysfunction: This can include problems with bladder and bowel control, sexual dysfunction, and abnormal blood pressure or heart rate regulation.

The symptoms are usually bilateral (affecting both sides of the body), though they may be asymmetric in some cases.

Diagnosis

Diagnosing transverse myelitis involves a combination of clinical evaluation and diagnostic testing to confirm inflammation and rule out other potential causes.

  • Magnetic Resonance Imaging (MRI) is the primary imaging technique used to detect inflammation and damage within the spinal cord. It can also help identify other possible causes such as tumors or spinal cord compression.

  • Lumbar puncture (spinal tap) may be performed to examine cerebrospinal fluid for signs of inflammation or infection.

    What the Analysis Looks For

        Inflammatory Markers:

        The CSF sample is analyzed for elevated white blood cells and protein levels.

    Oligoclonal Bands:

    The presence of specific oligoclonal IgG bands in the CSF is a key indicator of immune system activity within the central nervous system and is often seen in TM and MS.

    Other Markers:

    The analysis may also look for specific antibodies associated with other conditions, such as autoimmune disorders, to help rule them out

  • Blood tests can identify infections, autoimmune markers, and specific antibodies such as those related to neuromyelitis optica (NMO-IgG) or MOG antibody disease.

    Neuromyelitis optica (NMO-IgG) and MOG antibody disease are rare autoimmune disorders where the immune system attacks parts of the central nervous system.

    NMO-IgG (Neuromyelitis Optica Spectrum Disorder): Caused by antibodies against aquaporin-4 (AQP4), a water channel on astrocytes. It mainly affects the optic nerves and spinal cord, leading to vision loss and paralysis. AQP4-IgG is a key diagnostic marker.

    MOG Antibody Disease: Caused by antibodies against myelin oligodendrocyte glycoprotein (MOG), found on the surface of myelin in the CNS. It can cause symptoms similar to NMO but often includes brain involvement, optic neuritis, and inflammatory demyelinating syndromes.

    Though similar in symptoms, they differ in antibody targets, disease mechanisms, and treatment approaches.

Treatment

The main goal of treatment is to reduce spinal cord inflammation, manage symptoms, and address the underlying cause if identified.

  • Corticosteroids are typically the first line of treatment. High-dose intravenous steroids help suppress the immune response and reduce inflammation.

  • Plasma exchange (plasmapheresis) may be used if a patient does not respond to steroids. This procedure removes harmful antibodies from the blood.

  • Intravenous immunoglobulin (IVIG) therapy is another option, particularly in cases suspected to be autoimmune in nature.

  • Rehabilitation is critical during the recovery phase. Physical and occupational therapy can help patients regain mobility and independence.

In cases where an underlying disease such as MS or NMO is identified, long-term disease-modifying treatments may be necessary to prevent future episodes.

Prognosis

Recovery from transverse myelitis varies widely. Some patients recover fully, while others experience permanent impairments. Most improvement occurs within the first three to six months after the onset of symptoms, though recovery can continue for up to two years.

Factors influencing prognosis include:

  • The severity of initial symptoms

  • The speed of receiving treatment

  • The presence of an underlying chronic condition

Prompt diagnosis and treatment are critical for improving outcomes.

Conclusion

Transverse myelitis (TM) is a rare but potentially debilitating neurological disorder with a wide array of underlying causes, ranging from autoimmune diseases and infections to paraneoplastic syndromes and idiopathic inflammation. Due to its complex and variable nature, accurate diagnosis requires a comprehensive clinical evaluation. This typically involves a combination of neurological examination, magnetic resonance imaging (MRI) of the spinal cord and brain, and laboratory testing, including cerebrospinal fluid (CSF) analysis and blood tests to identify potential infections, autoimmune markers, or antibodies.

Identifying the specific cause of TM is critical—not only to guide appropriate treatment strategies, but also to help predict disease course and long-term outcomes. Some cases may respond well to immunosuppressive therapies or antiviral treatment, while others may require long-term rehabilitation and symptom management.

Although TM is uncommon, its impact on an individual's motor function, sensation, and autonomic control (e.g., bladder and bowel function) can be profound. Early diagnosis and prompt medical intervention are key to minimizing permanent neurological damage and improving the likelihood of recovery.

Ongoing research continues to enhance our understanding of transverse myelitis. Advances in diagnostic tools, biomarkers, and targeted therapies offer hope for more effective management and improved quality of life for those affected.

Anyone experiencing sudden or unexplained symptoms such as limb weakness, numbness, back pain, or changes in bladder or bowel function should seek immediate medical attention. Early recognition and treatment can significantly alter the trajectory of the disease and improve long-term outcomes.

References:

Extensive information:
Transverse myelitis, also known as acute transverse myelitis
https://radiopaedia.org/articles/transverse-myelitis

Transverse Myelitis
https://www.ncbi.nlm.nih.gov/books/NBK559302/#:~:text=Infections%20leading%20to%20TM%20include%20but%20are,reported%20to%20have%20an%20association%20with%20TM

Transverse Myelitis explained: https://www.youtube.com/watch?v=2lZqXdpgXNQ

 

© 2000-2025 Sieglinde W. Alexander. All writings by Sieglinde W. Alexander have a fife year copy right. Library of Congress Card Number: LCN 00-192742 ISBN: 0-9703195-0-9  

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