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ARTICLES: B. M. Greenberg, K. P. Thomas, C. Krishnan, A. I. Kaplin, P. A. Calabresi, and D. A. Kerr Idiopathic transverse myelitis: Corticosteroids, plasma exchange, or cyclophosphamide Neurology 2007; 68: 1614-1617 [Abstract] [Full text] [PDF]

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Idiopathic transverse myelitis: Corticosteroids, plasma exchange, or cyclophosphamide

Sudhir Kumar, G. Sandhya, G. Rajshekher, R. Reddy, S. Prabhakar   (30 July 2007)

Reply from the authors

Benjamin M. Greenberg, Douglas Kerr   (30 July 2007)

Idiopathic transverse myelitis: Corticosteroids, plasma exchange, or cyclophosphamide 30 July 2007
Sudhir Kumar, Apollo Hospitals Department of Neurological Sciences, Apollo Hospitals, Jubilee Hills, Hyderabad, India-500 033, G. Sandhya, G. Rajshekher, R. Reddy, S. Prabhakar Send Correspondence to journal: Re: Idiopathic transverse myelitis: Corticosteroids, plasma exchange, or cyclophosphamide drsudhirkumar{at}yahoo.com Sudhir Kumar, et al.	We read with interest the recent article in Neurology regarding the usefulness of adding plasma exchange (PLEX), cyclophosphamide (CP) or both to a course of intravenous methylprednisolone in patients with transverse myelitis (TM).[1] The authors concluded that in patients with TM who have ASIA A disability, combination of PLEX and CP showed benefit. In patients without ASIA A level of disability, PLEX (and not CP) provided benefit beyond steroids. We would like to make some specific points. Greenberg et al proposed to study the efficacy of immunotherapy in patients with “idiopathic” TM yet they have included patients with autoimmune diseases. Presence of connective tissue diseases is an exclusion criterion for a diagnosis of “idiopathic” TM. [2] There is no information on how the decision to use PLEX or CP or both was undertaken. Was it based on clinical severity or lack of response to intravenous steroids or presence of systemic autoimmune conditions or the treating clinicians’ choice? Did the institution have a written protocol which was followed for treating patients with TM? The treatment groups were heterogeneous in various aspects (such as disease severity, gender, presence of connective tissue diseases, etc) as mentioned in Table 1. Therefore, any definitive conclusions cannot be drawn regarding the superiority of one treatment protocol over another. Additionally, the patient numbers in CP and PLEX + CP were too small to derive any statistically significant conclusion. Duration of cyclophosphamide therapy is not mentioned. Adverse effects and complications of various therapeutic regimens are also not mentioned. Was there any mortality in the study group? References 1.Greenberg BM, Thomas KP, Krishnan C, Kaplin AI, Calabresi PA, Kerr DA. Idiopathic transverse myelitis: corticosteroids, plasma exchange, or cyclophosphamide. Neurology. 2007;68:1614-1617. 2.Transverse Myelitis Consortium Working Group. Proposed diagnostic criteria and nosology of acute transverse myelitis. Neurology. 2002;59:499-505. Disclosure: The authors report no conflicts of interest.
Reply from the authors 30 July 2007
Benjamin M. Greenberg, Johns Hopkins School of Medicine 600 North Wolfe St. Path 627 Baltimore, MD 21287, Douglas Kerr Send Correspondence to journal: Re: Reply from the authors bgreenb7{at}jhmi.edu Benjamin M. Greenberg, et al.	We thank Drs. Sandhya et al for their comments. Their analysis is insightful and provides us an opportunity to stress certain points regarding our recent retrospective analysis of treatment options for transverse myelitis. [1] There has been limited data published on the utility of various therapies and our article was an attempt to offer insight into some of the complex options available to neurologists. It is true that several of our patients turned out to have underlying autoimmune conditions and therefore would not be accurately defined as 'idiopathic' transverse myelitis. Yet, at presentation, these disorders may not have been known. These patients were included because identifying them after the fact has lead to certain pertinent insights. This includes the conclusion that patients with autoimmune conditions respond better to regimens that include cyclophosphamide. Our colleagues also correctly observe that a premeditated algorithm for treatment decisions was not presented in the methods section of this paper. This retrospective review collected data from 122 consecutive patients treated at Johns Hopkins who had complete data. There were inherent clinical biases that existed that cannot be quantified in a retrospective analysis. These were mainly based on prior experiences that provided empiric evidence used to direct care for future patients. This data, however, provides justification for a prospective controlled trial to test the presented hypotheses. We also acknowledge the heterogeneity and relatively small numbers in certain treatment groups. Collecting data for rare conditions is difficult. This paper is meant to provide insight into the largest cohort of acute transverse myelitis patients ever published. This will hopefully stimulate future research and clinical trials. The cyclophosphamide protocol used for treatment was a one time body surface area based calculation, specifically 1000 mg per meter squared. Disclosure: The authors report no conflicts of interest.