Clinical Reasoning: A 70-year-old man with rapid stepwise paraparesis and sensory loss

Abstract

A 70-year-old man with a history of cardioembolic stroke, hypertension, hyperlipidemia, peripheral vascular disease, and recently diagnosed myelodysplastic syndrome presented to an outside facility with acute sensory loss in the left buttock and lower extremity without weakness. Spine MRI demonstrated nonenhancing T2-hyperintense lesions in the upper thoracic cord and conus medullaris. MRI brain showed areas of nonspecific T2-hyperintensity. CSF revealed 20 total nucleated cells (TNC)/µL; 11,000 red blood cells (RBC)/µL; normal glucose, protein, and immunoglobulin G (IgG) index; 0 unique CSF oligoclonal bands; negative Gram stain, herpes simplex virus (HSV) 1/2 PCR, and Borrelia PCR; cytology was normal. Pleocytosis was attributed to traumatic lumbar puncture (utilizing correction of 1 TNC/µL per 500 RBC/µL), and history was inconsistent with HSV or subarachnoid hemorrhage as a cause of elevated RBCs. Serum aquaporin-4-IgG was negative. Mild anemia and thrombocytopenia were apparent. He was discharged with a provisional diagnosis of demyelinating disease. Three weeks later, he developed acute paraparesis with bladder and bowel dysfunction within hours. Repeat MRI at the outside institution showed enlargement of the nonenhancing lesions in the upper thoracic cord, now longitudinally extensive (≥3 vertebral body segments), and the lower thoracic cord extending into the conus (figure, A and E). Given concern for progressive demyelination due to motor decline and expanding lesions, IV methylprednisolone was initiated. Despite treatment, his paraparesis worsened and he was transferred to our facility.