Neuromyelitis Optica and Anti-MOG Disease Late Breaking Abstracts

LB1238 - Myelin Oligodendrocyte Glycoprotein-antibody positive transverse myelitis presenting as acute flaccid paralysis in a child with enterovirus infection (ID 2123)

Speakers
  • V. Salinas
Authors
  • V. Salinas
  • J. Lorenzo
  • C. Wang
Presentation Number
LB1238
Presentation Topic
Neuromyelitis Optica and Anti-MOG Disease

Abstract

Background

Acute transverse myelitis is an immune-mediated disorder targeting the spinal cord and manifests with weakness, sensory deficits, and loss of bowel and bladder control. It can occur as a part of a serologically-defined neuroimmunological syndrome or as monophasic post-infectious illness. While these conditions generally respond well to immunotherapies, direct infections of the spinal cord (e.g. enterovirus related acute flaccid myelitis [AFM]) fare poorly and theoretically could be negatively impacted by immunosuppressive treatments. The clinical and radiological overlap in these conditions poses challenges to acute management of a child presenting with acute flaccid limb weakness.

Objectives

We report a child who presented with subacute onset of flaccid paraplegia, anesthesia, and urinary retention with positive nasopharyngeal swab for enterovirus/rhinovirus (EV/RV), who was found to be positive for MOG antibodies.

Methods

Case report detailing the clinical presentation, laboratory findings, neuroimaging results, clinical decision-making, treatment, and hospitalization course.

Results

A 4-year-old previously healthy Hispanic boy presented with back pain and lower extremity weakness and numbness in July 2020. The symptoms evolved over several hours the previous evening and were preceded by an upper respiratory infection 2 weeks prior. His exam was notable for flaccid paralysis, areflexia, and anesthesia of his lower extremities and urinary retention.

Pertinent laboratory findings included nasopharyngeal swab detection of EV/RV, CSF with 222 WBCs/mm3, glucose 59 mg/dL, protein 171 mg/dL, elevated IgG index of 0.87, and negative CSF enterovirus PCR. Spine MRI demonstrated a longitudinally extensive transverse myelitis largely restricted to the gray matter. Brain MRI showed T2 hyperintense lesion in the right pons and left occipital white matter.

Given his profound leg weakness and potential in benefitting from empirically treating an immune-mediated myelitis, he received IV methylprednisolone and plasma exchange. Serum MOG autoantibody later returned positive (1:100). He regained volitional bladder function and had antigravity lower extremity movements following these treatments.

Conclusions

The case highlights the diagnostic challenges of a child presenting with acute flaccid weakness of unclear etiology. Our patient had demographic (age, seasonality), exam (flaccid, areflexic limbs), and laboratory features (enterovirus/rhinovirus positive on nasal swab) which combined were highly suggestive AFM. However, the presence of a supratentorial brain lesion and concern for an immune-mediated myelitis led to administration of immunotherapies prior to knowledge of his serological results. More efforts are needed to better define the unique characteristics associated with these syndromes to provide diagnostic and treatment guidelines.

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