Indicative signs and symptoms | Suggested evaluation |
Infectious etiology | |
Fever | CSF Gram stain and bacterial culture |
Meningismus | CSF PCR: HSV-1, HSV-2, HHV-6, VZV, CMV, EBV, enteroviruses D68 and EV71 |
Rash | CSF viral culture |
Concurrent systemic infection | CSF acid-fast bacilli smear and tuberculous culture |
Immunocompromised state | CSF HSV, VZV, and HTLV-1 antibodies |
Recurrent genital infection | CSF VDRL and CSF PCR for HSV |
Symptoms of zoster radiculopathy | CSF PCR for HSV |
Adenopathy | CSF India ink and fungal culture |
Residence in area endemic for parasitic infections | Chest radiograph and cranial CT scan |
Lymphadenopathy | Serology for antibodies to HIV, HSV, VZV, HTLV-1, B. burgdorferi |
Serology for hepatitis A, B, C, and Mycoplasma | |
Consider serology for parasites | |
Blood cultures | |
Systemic inflammatory disease (vasculitis, collagen vascular diseases, mixed connective tissue disease) | |
Rash | Serum ACE |
Oral or genital ulcers | Autoantibodies: ANA, ds-DNA, Ro/SSA, La/SSB, Sm, RNP |
Adenopathy | Complement levels |
Livedo reticularis | Urinalysis with microscopic analysis for hematuria |
Serositis | Lip/salivary gland biopsy |
Photosensitivity | Chest CT with intravenous contrast |
Inflammatory arthritis | Schirmer test |
Erythema nodosum | Chest radiograph |
Xerostomia | Gallium scan |
Keratitis | Antiphospholipid antibodies (anticardiolipin antibodies, Russel viper venom time, partial thromboplastin time) |
Conjunctivitis | |
Contractures or thickening of skin | |
Anemia/leukopenia/thrombocytopenia | |
Raynaud phenomenon | |
History of arterial and venous thrombosis | |
Multiple sclerosis | |
Previous demyelination event | Brain MRI |
Incomplete deficit clinically with MRI abnormality ≤2 spinal segments and <50% of cord diameter | CSF oligoclonal bands and IgG index |
Neuromyelitis optica spectrum disorder (NMOSD) | |
Optic neuritis | Brain MRI (usually negative) |
Clinical deficit with MRI abnormality ≥3 spinal segments | Serum anti-AQP4 IgG and anti-MOG IgG autoantibodies |
Paraneoplastic myelopathies | |
Spastic paresis with or without bowel and bladder dysfunction, usually with involvement of other areas of the nervous system | Paraneoplastic antibody panel |
Longitudinally extensive transverse myelitis on spine MRI | Cancer screening |
Idiopathic transverse myelitis | |
No clinical or paraclinical features suggestive of another diagnostic category | Rule out infectious etiologies, systemic inflammatory disease, CNS inflammatory disorders, and paraneoplastic myelopathies |
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