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A 43-year-old female Ghanaian office cleaner presented to the emergency department with a 2-day history of progressive, ascending lower limb weakness, with sensory disturbance and urinary retention. There were 2 weeks of non-specific, intermittent back pain, but she had been previously well. She was a lifelong non-smoker and did not drink alcohol. On examination, she had a left Horner's syndrome but the cranial nerves and upper limbs were otherwise normal. In the lower limbs, power was absent in all muscle groups, with areflexia and hypotonia. There was patchy sensory loss but no clear sensory level. Cardiovascular, respiratory and abdominal examinations were normal.
Initial laboratory results found microcytic …
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