To present a case of acute on chronic post-traumatic progressive myelopathy presenting with clinical and radiological longitudinally extensive transverse myelitis (LETM).

LETM is part of a larger spectrum of central nervous system inflammatory disorders characterized by immune-mediated demyelination that may suggest an underlying diagnosis of neuromyelitis optica spectrum disorder (NMOSD) or similar mimics. Trauma may also manifest with cord signal changes that suggest underlying demyelination, and is an important differential to consider.

Case report from a tertiary medical center.

A 31-year old male presented with rapidly progressive paraparesis, T1 sensory level, brisk LE reflexes and urinary retention after lifting heavy weights. MRI showed extensive longitudinal cord enhancement from T1-T8 with a non-enhancing nodular cystic lesion at T1-2, suspicious for LETM. Brain MRI, CT chest, and neuro-ophthalmic exam were unremarkable. CSF for infection and inflammation revealed a mildly elevated protein. Aquaporin 4 and MOG antibodies were negative. High-dose steroids and PLEX provided minimal improvement. One year prior to presentation, he suffered a penetrating stab wound to the spine that did not pierce the dura, but resulted in left hemisensory loss and mild left weakness. Prior MRI spine demonstrated T2 signal at T1-2 contiguous with an external penetrating injury. His presenting symptoms were attributed to acute progression of his prior spinal cord trauma precipitated by heavy weight lifting.

Post-traumatic progressive myelopathy (PTPM) is an under-recognized but important cause of myelopathy in patients with prior spinal cord injury. Our patient likely experienced an acute on chronic secondary inflammatory response clinically and radiologically manifesting as LETM. PTPM is an important etiology to consider before initiating chronic immunosuppressive therapy that may not benefit the patient.