Presentation
2 month history of neck pain with paresthesia. Associated with weight loss of 12 pounds, decreased appetite and night sweats.
Patient Data
On sagittal T2, there is long segment cord abnormality with hyperintensity and cord expansion. Appearances are consistent with a longitudinal extensive transverse myelitis (LETM). Unfortunately, contrast was not administered on this unsupervised GP referral list.
On soft tissue windows, marked mediastinal and hilar lymphadenopathy can be seen. On lung windows, multiple randomly distributed bilateral nodules are seen, with conglomerate subpleural plaques. No abnormality was found below the diaphragm (images not shown). The appearances favor stage II sarcoidosis, rather than lymphoma.
Patient started on steroids and methotrexate, with good clinical results. Follow up MRI at 6 weeks.
There is marked improvement in the degree of cord swelling and longitudinal extent of the cord hyperintensity.
Case Discussion
The differential for a LETM lesion is very extensive, and to narrow the differential, the radiologist needs to pay careful attention to the clinical presentation (e.g. bilateral visual loss with hiccups suggesting NMO), additional clues on the imaging (as on this case), consider scanning the brain and orbits (to see characteristic lesions of MS, ADEM or NMO), and advise serologic examination (e.g. NMO IgG, autoimmune serology, ACE levels) and CSF analysis. Despite all this, the specific cause of a LETM can be very challenging to diagnose.
In this case, the chest findings on spinal MRI prompted further evaluation for sarcoidosis, which allowed for correct diagnosis and appropriate treatment. This illustrates the importance of looking at the whole scan when reporting spinal MRI.
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