A 19-year-old man presented with a seven-year history of progressive paraparesis without autonomic disturbance. He was found to have bilateral pes cavus, spastic paraparesis, hyperreflexia in the lower limbs with suppressed reflexes in the upper limbs. Vibration sensation and joint position were impaired up to the ankles in the lower limbs.
MR scan of the brain and whole spine showed periventricular T2 signal change and striking T2 signal change in the posterior column, from the conus medullaris up to the mid brain.
Nerve conduction studies showed attenuated motor response in the lower limbs without clear evidence of conduction slowing. There was evidence of fibrillations in the distal lower limb muscles on needle examination.
Autoimmune screen showed positive ANA (1:40) with positive anti-Ro SSA and Scl-70 antibodies. Rheumatoid factor (1:320) and anti-cardiolipin antibodies were also present.
Lumbar puncture revealed paired oligoclonal bands in the CSF and serum, indicative of systemic inflammation.
The patient was found to have positive HBs and e antigens; consistent with a diagnosis of chronic active hepatitis B infection. Other viral studies were negative. Schirmer's test was negative; lip biopsy however, was in keeping with mild chronic inflammation. This is the first reported case of predominant involvement of the posterior column in a patient with active Hepatitis B.