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A 31-year-old man presented with a 2-week history of progressive paraparesis, leg numbness and urinary retention. He had no fever. Neurological examination identified paraplegia with hyper-reflexia in both lower limbs. Pain and proprioceptive sensation were decreased below the T7 level. Magnetic resonance (MR) scan of the spine showed a T2-hyperintense lesion extending from the fourth cervical vertebra level to the conus medullaris with the ‘flip-flop sign’ and the ‘candle guttering appearance’ (figure 1). MR scan of the brain was unremarkable. Cerebrospinal fluid (CSF) examination showed an elevated opening pressure (25 cm H2O) with no pleocytosis, glucose 1.7 mmol/L (25% of glycaemia) and protein 1.6 g/L. CSF PCR testing for varicella zoster virus, herpes simplex virus, cytomegalovirus and tuberculous mycobacteria were negative. Serum antiaquaporin 4 antibodies were absent. He …
Contributors CA: data collection, conception and drafting of the manuscript. JJ: critical review and revision of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned. Externally peer reviewed by Hadi Manji, London, UK.