Abstract

There are very few reports on the occurrence of transverse myelitis following tetanus toxoid injection. In our hospital, we had a 35- year-old white female who developed transverse myelitis approximately 10 days after tetanus toxoid vaccination. No other factors associated with Transverse myelitis were identified.

Introduction
Transverse myelitis has been reported following various viral infections and vaccinations. These have included Hepatitis B, Smallpox vaccine and Triple vaccines (diphtheria, polio and Tetanus).^[10] There are very few reports of Transverse myelitis following Tetanus Toxoid injection. One case was reported in Lancet in 1992 ^[6] regarding the incidence of Transverse myelitis and Tetanus Toxoid booster.

Case Presentation 
A 35-year-old right-handed white female with a past medical history of seizure disorder, received a Tetanus toxoid booster dose at work following a cut on her hand. Eleven days post-vaccination, she was assisting a resident and twisted her back. 20-30 minutes later, she developed a funny sensation and mild pain between her shoulders. Next day she developed back pain and numbness in the right lower extremity. Three days later, she developed onset of inability to void. She was then admitted in a local hospital and diagnosed with Cervical Transverse Myelitis. She received Steroid therapy there. Despite Steroid, she progressed to paraplegia and total loss of sensation up to the T-3 dermatomal level from below. When her condition did not improve, she was then transferred to Our Hospital for further evaluation.

General Physical: unremarkable
Neurological: examination

Motor Strength: 0/5 in both lower Extremities: Tone: Flaccid. 4=/5 in RUE and 1-2/5 in LUE

DTR: 0/4 throughout, plantar: no response.

Sensory: No sensation from T-2-3 levels distally. Decreased sensation in RUE proximally up to midforearm.

LAB: CSF finding: RBC-1, WBC-6; Total protein: 143, Glucose: 77, IgG index 0.62, myelin basic protein: -20, Oligoclonal bands: 0, Lyme titer (negative); Serology for RPR , HIV and EBV were negative. ANA, ESR Anti-cardiolipin antibody, RF were within Normal limits. Tetanus specific antibody was (IgG) 2.9 (ref: <0.1).

MRI of C-spine: Increased signal intensity at C3-4 and C5-6.

Fig: 1 and 2 T1 weighted MRI of Cervical spine showing contrast and post contrast Cervical Cord MS plaques at the level of C3-4 and C5-6.

MRI of Cervical spine showing Transverse Section of the Cord at that level.

MRI of brain was Normal. EEG and VEP were normal.

Hospital course
Initially she improved with high dose steroid, but condition deteriorated on oral tapering dose of steroid. She lost mobility in the right hand and developed severe pain in the left hand. She developed Horner’s syndrome in the left eye. She was immediately switched to IV Decadron. Over next couple of days, her condition improved. Dysesthesia of her hands improved with Tegretol and Elavil. She was transferred to Skilled Rehab Center.

Discussion:
Previous reports of Neurologic complications following Tetanus Toxoid have been reported in Lancet. ^[6] There is a report of Relapsing Neuropathy following Tetanus Toxoid.^[5] There is a report of The Brown-Sequard Syndrome following Diphtheria and Tetanus vaccine.^[2] Tezzon F and at el. reported a case of acute Radiculomyelitis after Anti tetanus vaccine.^[9] Neurological picture in our patients supports the diagnosis of Transverse Myelitis. A causal link between Transverse myelitis and Tetanus toxoid has been suggested by (a) Temporal association between these events (b) the previous reports of Transverse myelitis from Tetanus toxoid. (c) No clinical evidence of underlying illness. (d) High titer of Tetanus Specific antibody. It is difficult, if not impossible, to discount the temporal relationship between the vaccination and the onset of Transverse myelitis.

Pathogenesis
It is difficult to say the pathogenesis of Transverse myelitis but postulated that direct invasion of the Nervous system followed by Antigen-antibody reaction may be responsible.^[4] Pollard and Selby in their article pointed out that Tetanus toxoid caused acute idiopathic Polyneuropathy with the features of Onion bulbs and macrophage mediated demyelination. Studies of blastogenesis and macrophage migration inhibition, showed T lymphocyte responsiveness to both peripheral nerves and Tetanus toxoid. There is a study report of Brachial Plexus neuropathy by Beghi E at el. ^[8] following tetanus toxoid immunization. The occurrence of antecedent events and the features of the disease are supportive of the concept of immune mediated process. Our patient was normal 10/12 days before Tetanus Toxoid. She gave no history of recent viral infection. She suddenly developed Transverse myelitis with high tetanus specific antibody titer. With no underlying illness our assumption is that Tetanus Toxoid caused the disease.

References
1. Victor and Adams, Textbook of Neurology.

2. Naser UAMA A. Ghaffer, MRCP, Brown -Squad syndrome, following Diphtheria and Tetanus vaccine. Tropical Doctor, 1994, Apr 24 (2):74-5.

3. Whittle E at el. Transverse myelitis after Diphtheria, tetanus and polio immunization; British Medical journal, 1977, June 4 1(6074): 1450

4. Croft P.B: Para infectious and post-vaccinal encephalomyelitis. Post Grad. Med J 1969, 45:392- 400

5. Pollard-JD, Selby G: Relapsing neuropathy due to Tetanus toxoid. J-Neurol-Science .1978 jun, 37(1-2): 113-25

6. Stephen J. Read, Graham J. Schapel and Michael P. Pender: Acute Transverse myelitis after Tetanus Toxoid vaccination; Lancet 192, May 2, 339 (8801): 1111-2

7. Dr. Topaloglu at el: A case of optic neuritis and myelitis Lancet, Jan 18, 1992; 339(8786); 178-9

8. Beghi E, Leonard T. Kurland MD at el, - Brachial plexus neuropathy in the population of Rochester, Minnesota, 1970-1981, Annals of Neurology 1985; 18(3): 320-23

9. Tezzon F,Tomelleri-p, Ferrai-G , Sergi-A-and at el – Acute radiculo-myelitis after Anti tetanus vac. – Ital. Neurol. Sci , 1994 , May 15 (4) : 191 -3

10. Costa DF, Cooper A, Chir MB, Pye IF; -Transvers myelitis following Cholera, Typhoid and Polio vaccination. J. the Royal Soc. Of Medicine.1990 Oct, 83:653

11. Acute Transverse myelitis: Tetanus Toxoid vaccination (letter comment) Lancet 1992, Jan 18, 339 (8786): 178-9 and Lancet 1992 Aug.8; 340 (8825): 379

                                                                                                       
                                                                                                Dr. Abdul Baset Khan, MD
Dr. Abdul Baset Khan, MD, is a clinical neurologist who graduated from Mymensingh Medical College. In the USA, he completed his internship in medicine at Queens General Hospital, New York, and a neurology residency at KU Medical Center, KS. He is a board-certified clinical neurologist. In the recent past, he was head of the Department of Neurology at Ochsner Medical Center in Baton Rouge, LA. Currently, he is an assistant professor of neurology at UTMB. He has given numerous lectures on neurology in the United States and Bangladesh. He is involved in several neurological professional societies. He has been an elected member of scientific society and professional organizations. He remains busy with patient care, teaching, and scholarly activities.