Case We present a 64 year old gentleman with previous non-metastatic melanoma and newly diagnosed myeloma, for which he had received steroids but not chemotherapy. He developed fever followed by an ascending acute flaccid paralysis with brainstem involvement, requiring ventilatory support within hours of onset. MRI demonstrated an extensive enhancing longitudinal spinal cord lesion with signal change in thalami, temporal lobes and pons. CSF protein was >6 g, WCC 150 (90% neutrophils), no organisms and negative virology. Neurophysiology demonstrated a selective motor neuropathy/neuronopathy.
H1N1-influenza A (‘swine flu’) RNA was detected on nasopharyngeal aspirate. He was treated with Zanamavir, antimicrobials, steroids, and plasma exchange. His clinical improvement remains slow, and he will require long-term care.
Discussion This patient developed a rare, catastrophic neurological complication of pandemic FluA, in the context of untreated multiple myeloma. Whilst not a pure acute flaccid myelitis, this case highlights the need to be aware of uncommon neurological complications of viral infections.
There has been a peak in 2018 of cases of acute flaccid myelitis across the UK, Europe, and America. Public Health England has declared a national incident in response to this. The cause remains unproven, and neurologists should report suspected cases to PHE.
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