Introduction

Intrathecal drug delivery a method of directly administering opioid and spasmolytic medication to the site of action, the spinal cord (1). Efficacy and safety of this delivery system is well documented in cancer pain, spacticity as well as non-malignant pain (2). However, there are a number of recognised potential complications with this therapy. One of the most serious of which is the formation of a granuloma occurring at the intrathecal catheter tip, which appears to be related to the concentration and drug type being delivered (1). Evidence has indicated that delivery of high dose morphine can lead to the formation of these granulomas (3, 4). Occurring in less that 3% of all patients with an intrathecal catheter, granulomas can present as an inflammatory mass on imaging with some resulting in compression of the spinal cord (5). Patients may present with a host of neurological symptoms dependent on the location of cord compression caused by the granuloma, including neurological deficits, myelopathy and radiculopathy.
An important differential to consider in patients with intrathecal catheters presenting with neurological deficits is transverse myelitis (TM). TM is a neuroinflammatory condition affecting the spinal cord. It can present as a loss of corticospinal, autonomic and spinothalamic functional loss below the level of the lesion (6). TM has been reported to result from intrathecal device related infections, but may also be a consequence of demyelinating disorders, such as multiple sclerosis and neuromyelitis optica, vascular causes and malignancies, such as lymphoma. Therefore, early recognition of the cause of TM is paramount in preventing irreversible paralysis and further neurological deficits (7).
Here we report a case of transverse myelitis, caused by a B cell lymphoma, in a patient with an intra-thecal catheter.