We describe a 62-year-old smoker, presenting with a 6-week evolving history of progressive weakness of his legs and right hand, with sphincter disturbance. Past medical history included latent tuberculosis aged 25, which was treated. MRI whole-spine revealed longitudinally extensive transverse myelitis (LETM) spanning C4-T1. CSF examination revealed WCC 43 (93% lymphocytes), protein 844 mg/L, normal paired glucose, unmatched CSF oligoclonal bands, negative viral PCR, AFB, and mycobacterial culture, and cytology in keeping with chronic inflammation. He was treated with intravenous steroids with an oral taper; however, he made no improvement. Aquaporin-4 and anti-MOG antibodies were negative. Anti-Hu antibodies were strongly positive. CT thorax revealed a right hilar mass with mediastinal lymph node enlargement. Whole-body FDG PET-CT was in keeping with a primary lung malignancy. EBUS-guided fine needle aspiration confirmed a histological diagnosis of small-cell lung cancer. Oncology MDT deemed the tumour to be inoperable and he was treated with palliative chemotherapy. To our knowledge, this is the first reported case of paraneoplastic LETM, secondary to small-cell lung cancer, associated with positive anti-Hu antibodies. This case highlights that a paraneoplastic work-up should be considered early in LETM, particularly in older patients and those with risk factors for cancer.
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