POSTVACCINATION TRANSVERSE MYELITIS IN THE POSTPARTUM PERIOD: CASE REPORT AND LITERATURE REVIEW

Transverse myelitis (TM) is a clinical syndrome in which an inflammatory process injures the spinal cord potentially resulting in weakness, sensory abnormalities and autonomic dysfunction. The main causes are post-infectious, post-vaccination, autoimmune and demyelinating diseases. In a literature review based on five cases of TM during pregnancy and puerperal period have been reported. We report a female patient in the immediate postpartum period who presented acute transverse myelites after receiving double viral vaccine (measles and rubella). After exclusion of other causes, patient received methylprednisolone in high doses ( 1000 mg for 3 consecutives days)  and had complete clinical reversal. Thus it is intended to report this rare occurrence which is post-vaccination TM in the postpartum period.

Transverse myelitis (TM) is a rare syndrome that presents with neurological deficits secondary to an inflammatory process that causes lesions, acute or subacute, in the spinal cord potentially resulting in weakness, sensorial alterations and autonomic dysfunction 1 .
Incidence of transverse myelitis range from 1.3 to 8 cases per million, there is a bimodal peak in the incidence at 10 to 19 years of age and at 30 to 39 years 2 .Transverse myelitis syndrome arise from various causes, but it most often occurs as an autoimmune phenomenon after an infection or vaccination 3 .In pregnancy and puerperium few cases of TM are reported, mostly related to epidural anesthesia 4,5 .
The publication of this case has been authorized by patient and family, and the text submitted for approval by the ethics committee on research Hospital Cesar Cals, with favorable report number 1.603.060,according to the Resolution 466 of the National Health Council (CNS).

INTRODUCTION CASE REPORT
Patient 18 was admitted to the emergency department at gestational ages of 36 weeks featuring hypertension (200x120mmHg) associated with headache in occipital region and proteinuria.On the second day of hospitalization, after stabilization, cesarean section was performed through a transverse incision of the lower uterine segment, and a healthy infant was delivered.After giving birth, became asymptomatic with good blood pressure control.On the third postoperative day received double viral vaccine (measles and rubella) to update the vaccination calendar.On the fourth day developed rapidly progressive paraparesia of the lower limbs, associated with sensitive level (T4), hyperreflexia, ankle clonus, bilateral Babinsk signal and autonomic dysfunction.Cerebrospinal fluid analysis was perfomed, including cell count and differential, protein, glucose, VDRL, oligoclonal bands, immunoglobulin G index, and cytology.Serum was analysed for the presence of NMO-IgG antibodies (antiaquaporin-4 IgG), B12, methylmalonic acid, human immunodeficiency antibodies, syphilis serologies, serum ANA, Ro/SSA, and La/SSB antibodies (Table 1).After extensive investigation, not being found secondary causes of TM, we considered the diagnosis of post-vaccination myelitis The patient received treatment with high dose corticosteroids (1000 mg methylprednisolone) for 3 days.The patient had a good response, with full recovery of strength, sphincter control and sensitive symptoms.It was discharged 23 days after the event for outpatient follow.

DISCUSSION
The TM arise from various causes, most often occuring as an autoimmune phenomenon after an infection or vaccination (accounting for 60% of the cases) or as a result of an underlying systemic autoimmune disease, or an acquired demyelinating disease such as multiple sclerosis or related to neuromyelitis optica 6 .
In literature, there are few reported cases of TM in pregnancy or puerperium 4,5,[7][8][9] , caused by epidural anesthesia in 40%, lupus erythematosus 20%, schistosomiasis 20% and idiopathic in 20%.All patients received steroids in high doses achieving partial or complete response in 80%.Pregnancy and pueperium have unique hormonal, immune and mechanical changes, favoring the onset of several neurological illness .TM is little studied in this context, the inflammatory disease most studied in pregnancy is Multiple Sclerosis (MS).By making an analogy to MS cases , the postpartum period, due to changes in the immune balance, is suscetible to flares of inflammatory Th1 immunity, and if multiple sclerosis is a Th1-mediated disease, then it might follow that the increased risk of flare in disease activity postpartum may be due to a post-pregnancy shift of maternal immunity away from Th2 bias 10 .
Measles is a highly contagious, and preventable, viral infection characterized by fever and exanthem.Measles vaccination has markedly reduced the incidence of measles virus infection, with very

CONCLUSIONS
The patient described presented with classic clinical and neuroimaging manifestations of acute transverse myelitis.Data from randomized trials to inform the treatment specifically for patients with transverse myelitis are lacking; however, on the basis of clinical experience and trials involving patients with other demyelinating diseases, high-dose corticosteroids are considered to be the first-line therapy.
There is few information on such condition in pregnancy and postpartum period, and it is considered a rare event.The puerperal period by changes that restore immune response, is susceptible to inflammatory diseases flares.
few adverse events.vaccinationdoes not Appear to cause aseptic meningitis, subacute sclerosing panencephalitis, encephalitis, and Guillain-Barre syndrome.One Chinese study reported one case of Acute disseminated encephalomyelitis 3 days after measles vaccination during an outbreak 11 .Even though we have not found any cases reporting transverse myelitis after measles and rubella immunization, extensive diagnostic evaluation effectively ruled out causes other than vaccination-associated TM.In theory any vaccine can cause post-vaccination TM via a possible autoimmune mechanism against the myelin sheath of the central tract.
The mainstay of treatment of transverse myelitis, in order to hasten the resolution,is with corticosteroids.Due to the rarity and diversity of presentation of the disease,there are no randomized studies with this specific population, such conduct is extrapolated from studies in patients with multiple sclerosis and case reports.Approximately one third of patients have full functional recovery, one-third have partial recovery and one-third have severe disability despite treatment 6 .
MRI of the entire spine, with and without gadolinium 161 Brazilian Journal of Medicine and Human Health.2016 Dez4(4):160-163 was perfomed to evaluate for compressive versus noncompressive cord lesion, indicating discrete signal changes, affecting the posterolateral aspect of the central marrow, in the level of T4 and T3-T4-T5 without contrast enhancement suggesting transverse myelitis (figure1).

Figure 1 .
Figure 1.MRI of Thoracic Spine evidencing signal changes, affecting the posterolateral aspect of the central marrow, in the level of T4 (Arrow).

Table 2 .
Reported Cases of TM in pregnancy and puerperium.