Acute transverse myelitis excluding MS, NMOSD and MOGAD: A 15-year real-world cohort from Iran.

STUDY

DESIGN

Retrospective observational study

OBJECTIVES

To describe the demographic, clinical, laboratory, and imaging characteristics of patients with acute transverse myelitis in a tertiary referral center in Iran, with particular emphasis on uncommon etiologies and real-world diagnostic constraints.

SETTING

Iran

METHODS

This retrospective observational study was conducted at a tertiary referral center in Iran. Medical records of patients with acute transverse myelitis evaluated between March 2008 and December 2023 were reviewed. Diagnosis was made based on the Transverse Myelitis Consortium Working Group (TMCWG) criteria and/or expert clinical judgment reflecting real-world practice, supported by clinical presentation, neuroimaging findings, exclusion of alternative diagnoses, and response to treatment. Patients with multiple sclerosis or neuromyelitis optica spectrum disorder were excluded. Demographic, clinical, laboratory, imaging, treatment, and follow-up data were collected.

RESULTS

The number of patients was 22, and the average age was 37.05 years, with a female-to-male ratio of 1.75. Four patients (18.2%) had systemic autoimmune-related etiologies, four patients (18.2%) had infection-related etiologies, and two patients (9.1%) had acute transverse myelitis after vaccination. More than half of the cases (54.5%) were classified as idiopathic. During follow-up, four of the nineteen monitored patients experienced relapse. Most patients (84.2%) showed clinical improvement after treatment. The thoracic region was the most common segment on spinal magnetic resonance imaging. Enhancement with gadolinium was more common in idiopathic cases, although imaging findings were heterogeneous.

CONCLUSION

This study provides a real-world description of acute transverse myelitis in a low-middle-income setting. Idiopathic cases were frequent, and systemic autoimmune disorders represented important identifiable causes. Imaging and clinical outcomes were heterogeneous, emphasizing the need for cautious interpretation and larger prospective studies. This study highlights the etiologic spectrum and outcomes of ATM in a resource-limited setting, underscoring diagnostic gaps such as limited antibody testing and their impact on classification and relapse prediction.