Multiple Sclerosis and other Neurological Conditions
Norris Akpan, MD
Resident Physician
Rush University Medical Center
Chicago, Illinois, United States
Fatima Fontus, MD
Resident Physician
Lakeland Regional Health
Lakeland, Florida, United States
Kiana Brown, MSc
Teacher
Dallas Independent School District
Grand Prairie, Texas, United States
Gerard Dysico, MD
Attending Physician
Stroger Hospital
Chicago, Illinois, United States
Norris Akpan, MD
Resident Physician
Rush University Medical Center
Chicago, Illinois, United States
A 66-year-old Black female with medical history of C1-C4 spinal fusion and cervical lesion presenting with neuromyelitis optica spectrum disorder (NMOSD).
Case Description:
The patient presented with difficulty walking and an acute, severe headache described as the worst in her life. Vitals were normal except for blood pressure elevated to 210/102. On examination, there was diminished right-sided sensation and profound right hemiparesis.
Subarachnoid hemorrhage versus acute stroke were initially suspected, however, negative CT head, MRI brain, and echocardiogram did not support these theories. Cervical lesion biopsy obtained during previous spinal fusion showed focal necrosis and focal loss of astrocytic processes, and cervical MRI showed new C2-C4 hyperintensities. Given the biopsy results, hemiparesis, paresthesias, and area postrema syndrome, the working differential was broadened to consider a neuroinflammatory condition, which led to the diagnosis of NMOSD. She was treated with methylprednisolone with improvement in sensation and discharged to acute rehabilitation.
Discussions:
Patients with thunderclap headache and acute neurologic deficits are often evaluated for subarachnoid hemorrhage or stroke, but NMOSD should also be considered. NMOSD involves IgG autoantibody attacks against aquaporin- 4 or myelin oligodendrocyte glycoproteins on astrocytes, though, as seen in this patient, ~30% of cases are antibody-negative. Key clinical features of NMOSD seen in this case include acute severe transverse myelitis, nausea from area postrema syndrome, and MRI lesions spanning ≥3 contiguous segments. The patient improved in strength and sensation after methylprednisolone. As a hair-braider, manual dexterity, strength, and proprioception is vital to quality of life, underscoring the importance of individualized therapy and adaptive supports such as AFO bracing and resting hand splints.
Conclusions: This case highlights the importance of maintaining a broad differential when approaching patients with acute, neurological symptoms. Accurate, rapid diagnosis of NMOSD allowed for prompt, appropriate treatment that ultimately allowed for improvement in strength and function.
