Disclosures: Alex Vertes, MD, MPH: No financial relationships or conflicts of interest

Case Diagnosis: 73-year-old female with acute transverse myelitis and bilateral lower extremity weakness

Case Description or Program Description: This patient presented with acute weakness and paresthesias for 1 day following chemotherapy and immunotherapy (carboplatin/gemcitabine/pembrolizumab) treatment for lung cancer. Neurological exam demonstrated diminished bilateral lower extremity strength and sensation along with brisk reflexes and inability to stand. Laboratory studies were non-diagnostic and lumbar puncture for cerebrospinal fluid analysis was unsuccessful. Spine MRI was negative for cord compression without spinal cord enhancement or signal disturbance. The patient was clinically diagnosed with MRI negative transverse myelitis (TM) and started on steroids (methylprednisolone 1000 mg IV for 5 days).

Setting: Tertiary Care Academic Hospital

Assessment/Results: The patient showed significant recovery of neurological deficits starting 2 days after a 5-day course of methylprednisolone. Lower extremity strength improved gradually over a 2-week course of acute rehabilitation.

Discussion (relevance): TM is caused by inflammation of the spinal cord and presents with motor weakness, sensory impairment, and autonomic dysfunction. Diagnosis is established clinically or by MRI which demonstrates spinal cord contrast enhancement. TM is most often idiopathic or secondary to autoimmune and infectious processes but can also result from chemotherapy and immunologic therapies. In the past, systemic cisplatin and intrathecal chemotherapies including methotrexate have been shown to have neurotoxic effects including TM. While there are no reported cases of TM following carboplatin or gemcitabine alone, there are some recent cases attributed to pembrolizumab. However, to our knowledge no cases of TM following pembrolizumab have been associated with MRI negative TM.

Conclusions: We highlight a unique case of MRI negative TM as an adverse effect following administration of carboplatin, gemcitabine, and pembrolizumab. Recognition of neurologic complications of various chemotherapeutic and immunologic agents is crucial as dose adjustment, substitution, or discontinuation of therapies may prevent further neurologic injury.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/mri-negative-transverse-myelitis-following-chemotherapy-and-immunotherapy-a-case-report/