A 42-year old previously well man presented with a ten-day history of a flu-like illness, headache, back pain and urinary retention. He deteriorated in hospital with pyrexia and agitation and developed acute respiratory compromise necessitating intubation. MR imaging of the neural axis demonstrated enhancement of the leptomeninges, the splenium of the corpus callosum and patchy enhancement of the cervical and thoracic cord. CSF analysis revealed a white cell count of 211 (95% lymphocytes), protein 2.96 g/L and glucose 3.2 mmol/L (serum glucose 9.6 mmol/L).
Initial working diagnosis was of a meningoencephalitis with a transverse myelitis and given the clinical presentation and CSF findings an infectious aetiology was strongly considered. Treatment with anti-bacterial, anti-viral, anti-fungal and anti-tuberculous agents was initiated. Repeated CSF testing yielded negative PCR and culture results for a range of bacterial and viral causes, including tuberculosis. HIV was negative. Aquaporin-4 and MOG antibodies were negative.
A neuro-inflammatory cause, most probably post-infectious, was considered, and steroids initiated. This patient showed a good response to high dose oral steroids, improving over a number of weeks from complete quadriparesis with facial paralysis and ophthalmoplegia to regaining excellent facial and upper limb strength.
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