Case description

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 …