Short communication Intramedullary spinal cord metastasis from salivary ductal carcinoma of the parotid gland mimicking transverse myelitis in a patient with radiologically isolated syndrome Dale Ding a, ⁎, Michelle Fullard b , Heather S. Jarrell c , David E. Jones b a University of Virginia, Department of Neurological Surgery, P.O. Box 800212, Charlottesville, VA 22908, United States b University of Virginia, Department of Neurology, P.O. Box 800394, Charlottesville, VA 22908, United States c Virginia Commonwealth University, Department of Pathology, P.O. Box 980662, Richmond, VA 23298, United States abstract article info Article history: Received 23 September 2013 Received in revised form 16 October 2013 Accepted 18 October 2013 Available online 27 October 2013 Keywords: Spinal cord neoplasms Parotid neoplasms Neoplasm metastasis Transverse myelitis Multiple sclerosis Radiologically isolated syndrome Intramedullary spinal cord metastases (ISCMs) are rare lesions but their presence should not be underestimated in a cancer patient with rapidly progressive neurological compromise. Due to similar timing of clinical progres- sion and imaging characteristics, these lesions may be misdiagnosed as transverse myelitis, an inflammatory dis- order of the spinal cord that may be idiopathic or secondary to other diseases including infections, connective tissue disorders, nutritional deficiencies, and demyelinating disorders. We present a case of a 44 year-old male with a history of parotid gland metastatic salivary ductal carcinoma (SDC) and incidental demyelinating white matter lesions on brain magnetic resonance imaging (MRI) diagnosed as radiologically isolated syndrome with a CSF that was positive for oligoclonal bands. The patient initially presented with mid-thoracic dermatomal numbness, bilateral lower extremity weakness, and neurogenic bladder. MRI spine demonstrated an enhancing T5–7 intramedullary lesion initially diagnosed as transverse myelitis. After progressing to complete motor and sensory loss below T6 despite high-dose intravenous steroids and plasmapheresis, surgical biopsy was undertak- en. Intraoperative findings revealed an intramedullary tumor for which a subtotal resection was performed. Pa- thology was consistent with a metastatic deposit from the patient's primary parotid SDC. The patient underwent postoperative chemotherapy but expired due to systemic disease progression seven months following surgery without neurological improvement. This is the first reported case of ISCM from a primary SDC. The median sur- vival is 6 months for patients with ISCMs treated surgically. The goals of surgery are spinal cord decompression, functional preservation, and tissue diagnosis. © 2013 Elsevier B.V. All rights reserved. 1. Introduction While the spine is a common destination for metastatic cancer spread, intramedullary spinal cord metastases (ISCMs) are extremely rare, com- prising less than 1% of all spinal neoplasms and 1–3% of intramedullary spinal cord tumors [1–3]. Only 300 cases of ISCMs have been reported in the literature, with lung cancer as the primary malignancy in approxi- mately 50% of cases [3]. Transverse myelitis (TM) is an inflammatory dis- order of the spinal cord that may be idiopathic or secondary to other processes including infections (i.e., HIV, HTLV 1/2), connective tissue disorders (i.e., systemic lupus erythematosis, sarcoidosis), nutritional deficiencies (i.e., B12 or copper deficiency), and demyelinating disease (i.e., multiple sclerosis, neuromyelitis optica) [4]. Due to marked vari- ability in the etiology or TM and potential similarities in the clinical pre- sentation and radiographic characteristics between TM and ISCMs, it may initially be difficult to distinguish the two entities [5]. The widespread use of imaging, especially magnetic resonance im- aging (MRI), has led to a large increase in incidental findings in patients. Classically, the diagnosis of multiple sclerosis (MS) was made based on evidence of two or more clinical attacks disseminated in time and space. A first attack was classified as a clinically isolated syndrome (CIS), for which MRI disease burden could predict risk of progression to MS. Although the McDonald diagnostic criteria for MS incorporate MRI find- ings to demonstrate this dissemination in time and space, it requires at least one clinical attack to make the diagnosis of MS [6]. The radiologi- cally isolated syndrome (RIS) refers to the incidental finding of asymp- tomatic brain lesions on MRI that are highly suggestive of multiple sclerosis based on lesion distribution and morphology in a patient with- out a clinical attack. Common reasons for the MRI leading to discovery of RIS include headache, trauma, suspected vascular disease, and family history of demyelinating disease [7]. The natural history of RIS is still being defined; however, a large case series from UCSF suggests that the finding of demyelinating lesions in the cervical spinal cord predicts the risk of future clinical activity and conversion to MS [8]. The presence of oligoclonal bands may predict Journal of the Neurological Sciences 336 (2014) 265–268 ⁎ Corresponding author. Tel.: +1 434 924 2203; fax: +1 434 243 6726. E-mail address: dmd7q@hscmail.mcc.virginia.edu (D. Ding). 0022-510X/$ – see front matter © 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jns.2013.10.025 Contents lists available at ScienceDirect Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns