When Tuberculosis Strikes the Spinal Cord: A Rare Case of Longitudinally Extensive Transverse Myelitis

Spinal cord tuberculosis (TB) accounts for 1% of central nervous system TB cases. Longitudinally extensive transverse myelitis (LETM) is a rare clinical manifestation of TB, primarily reported in endemic regions. It presents clinically as rapid-onset weakness, sensory deficits, and bowel/bladder dysfunction with a band-like sensation. The etiology can be broadly divided into idiopathic, para-infectious, autoimmune, or vascular. A 70-year-old male presented in spinal shock with acute-onset weakness and numbness of bilateral lower limbs associated with autonomic dysfunction with bowel and bladder involvement. Magnetic resonance imaging (MRI) demonstrated T2 intramedullary hyperintensity extending from C3–C4 to T11, consistent with LETM. Further, cerebrospinal spinal fluid (CSF) analysis revealed high protein levels, low glucose, and lymphocytic pleocytosis. The cartridge-based nucleic acid amplification test (CBNAAT) was positive for M. tuberculosis with sensitivity to rifampicin. The patient responded well to pulse corticosteroid therapy with improved motor and sensory function. He was initiated on anti-tuberculosis therapy (ATT), and oral corticosteroids were continued. LETM is a rare but serious complication of TB. CSF analysis and MRI are critical for diagnosis. High-dose pulse corticosteroids and ATT form the cornerstone of treatment, and yield significant clinical improvement. This case underscores the importance of considering TB as an etiology for LETM in endemic regions. A high index of suspicion, coupled with prompt diagnosis, treatment, and early neuro-rehabilitation, is essential to optimize outcomes.