Nontraumatic myelopathy in Malawi: A prospective study in an area with high HIV prevalence

Abstract

Nontraumatic myelopathy causes severe morbidity and is not uncommon in Africa. Clinically, patients often present with paraplegia, and extrinsic cord compression and transverse myelitis are most common causes. Data on exact pathogenesis are scanty because of limitations in diagnostic methods. In Queen Elizabeth Central Hospital, Blantyre, Malawi, we recorded consecutive patients presenting with nontraumatic paraplegia for maximally 6 months between January and July 2010 and fromMarch toDecember 2011. Thediagnosticworkup included imaging and examiningblood, stool, urine, sputum, and cerebrospinal fluid (CSF) samples for infection. After discharge, additional diagnostic tests, including screening for virus infections, borreliosis, syphilis, and schistosomiasis, were carried out in the Netherlands. The clinical diagnosiswas, thus, revised in retrospectwith amore accurate final differential diagnosis.Of 58 patients included, themean age was 41 years (range, 12-83 years) and the median time between onset and presentation was 18 days (range, 0-121 days), and of 55 patients tested, 23 (42%) were HIV positive. Spinal tuberculosis (n = 24, 41%), tumors (n = 16, 28%), and transversemyelitis (n=6, 10%)weremost common; in sixcases (10%), nodiagnosiscouldbemade.Theadditional tests yieldedevidence forCSF infectionwithSchistosoma, Treponemapallidum,Epstein-Barr virus (EBV),HHV-6, HIV, aswell as a novel cyclovirus.The diagnosis of the cause of paraplegia iscomplex andrequires access to anmagnetic resonance imaging (MRI) scan and other diagnostic (molecular) tools to demonstrate infection. The major challenge is to confirm the role of detected pathogens in the pathophysiology and to design an effective and affordable diagnostic approach.