A Case Report on an Adolescent with Transverse Myelitis and Suspected Conversion Disorder
Scharff K, Lipa B, Russell H
Shriners Hospitals for Children - Philadelphia, Philadelphia, PA, 19140
Introduction: This case describes the multidisciplinary evaluation and treatment of a 15-year-old female with a diagnosis of transverse myelitis (TM) whose functional mobility was negatively impacted by suspected conversion disorder (CD).
Case Presentation and Timeline: The patient was diagnosed with TM at age 13 with absent BLE movement at onset. She was referred for outpatient evaluation at a pediatric spinal cord injury (SCI) specialty center one year later. ISNCSCI score at age 15 was T3 AIS D. The patient’s stated goals for rehabilitation were to ambulate and return to cheerleading. Over the following two years, the patient’s progression toward functional ambulation was prevented by abnormal movement patterns not consistent with her diagnosis of TM.
Diagnostic Focus and Assessment: The patient presented at initial assessment with significant spasticity in the bilateral lower extremities (BLE); obesity (body mass index 36); abnormal movement patterns not consistent with spasticity related to TM; weakness in the right lower extremity (RLE) but normal strength in the left lower extremity (LLE); and functional mobility inconsistent with her level and severity of injury. She was interviewed by the psychologist who concluded that the abnormal movements were not intentional.
Therapeutic Focus and Assessment: Multidisciplinary treatment included upright mobility training, botulinum toxin injections to address spasticity, psychotherapy sessions, and patient and parent education. Progression of upright mobility training was discontinued by the physical therapist due to safety concerns related to the patient's abnormal movement patterns. It appeared that abnormal movements frequently occurred whenever the patient’s medical condition was discussed and were absent when the patient was distracted. During a brief evaluation, the psychologist was unable to identify an emotional etiology.
Follow-up and Results: After three years, the patient continues to use a wheelchair for all mobility, standing only for exercise, as ambulation is still unsafe. She has not received counseling as recommended due to lack of health insurance and poor follow-up at home, even after the social worker provided the parents with information to obtain insurance for the patient. The patient continues to present with abnormal movement patterns that are inconsistent with her diagnosis of TM. However, she continues to express a desire to ambulate and return to cheerleading.
Discussion: This patient presents with right lower extremity weakness, impaired sensation in the trunk and BLE, and BLE spasticity consistent with TM at the T3 level. Medically, this patient should be able to ambulate functionally, but she does not, secondary to unintentional physical movements which cannot be explained by her underlying medical diagnosis. A possible CD is suspected, for which she has not sought psychological treatment.
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