Severe Transverse Myelitis Following Ankle Surgery Potentially Unmasking Late-Onset Systemic Lupus Erythematosus

A 70-year-old female underwent open reduction and internal fixation (ORIF) of her right ankle following a mechanical trip and fell two weeks before hospital admission. Two weeks following surgery, the patient experienced sudden-onset bilateral anterior thigh paresthesias and burning mid-back pain. Over the ensuing two days, the patient developed bilateral lower extremity weakness, bilateral lower extremity numbness, and urinary retention with constipation, which led to hospital presentation. A non-contrast cervical/thoracic/lumbar spine MRI on the day of admission revealed a possible syrinx from T3-T12. A repeat thoracic spine MRI revealed enhancement of the spinal cord at T9-T10 and T11-T12, suggestive of transverse myelitis or spinal cord infarction. Initiation of IV methylprednisolone sodium succinate improved strength and sensation, and IVIG (intravenous immunoglobulin) therapy was initiated. Transverse myelitis is typically idiopathic or attributed to infectious causes or systemic autoimmune conditions. Spinal cord injury remained high on the differential diagnosis, considering transverse myelitis rarely presents in the postoperative period. While methylprednisolone sodium succinate is the first-line treatment for transverse myelitis, its role remains unclear in treating spinal cord injury. Given the patient's positive response to methylprednisolone sodium succinate, an autoimmune panel was sent to determine the underlying etiology, resulting in a positive ANA (antinuclear antibody) and anti-dsDNA. Thus, transverse myelitis may be an initial presentation of systemic lupus erythematosus (SLE). In rare cases of spinal cord injury versus immune-mediated disorders affecting the spinal cord, corticosteroid treatment should be considered pending diagnosis confirmation.