A 20-year-old woman was admitted to our hospital for weakness, numbness, and pain in the limbs for 6 months and worsened for 3 days. The patient felt persistent pain in the neck, left shoulder, and the upper left arm 6 months before, and the situation became worse and both upper extremities were affected. The patient visited the local hospital and was diagnosed as myelitis and she received gamma globulin (20 g for 5 days) and dexamethasone (5 mg for 15 days). Her symptoms were improved gradually. However, 1 month later, the weakness, persistent numbness, and pain in both lower extremities occurred again and gradually worsened with time. Therefore, the patient returned to the local hospital, and received vitamin B12 treatment, her symptom became slightly better but not completely recover. Six days before the admission to our hospital, the patient had symptoms of sneezing nose. Three days later, the patient had severe weakness and numbness in the lower extremities. Her past medical history was otherwise negative except for PTB for 6 years. At that time, the patient received systematic anti-tuberculosis treatments and her symptoms were completely disappeared and chest computed tomography (CT) showed chronic pulmonary tuberculosis.
Neurological examination revealed decreased muscle strength of both lower extremities (1/5 of the right extremity and 3/5 of the left extremity according to the Medical Research Council [MRC] grade) with bilateral hyperreflexia. Bilateral Babinski sign were positive. Hyperalgesia was found below the level of T8, deep sensation of the right lower limb was absent. The Expanded Disability Status Scale (EDSS) of the patient during hospitalization was 6.5. The magnetic resonance imaging (MRI) scan of the cervical spine (6 months before admission) revealed cervical spinal cord lesions without gadolinium enhancement (Fig. 1). The serum anti-AQP4-Ab was strongly positive, and the Immunoglobulin G (IgG) oligoclonal bands were negative both in the serum and in the cerebrospinal fluid (CSF). CSF routine test showed elevated protein levels (0.39 g/L, normal range from 0.15 to 0.45 g/L) and increased cell numbers (leukocyte count 25 x 106/L, normal range from 0 to 8 x 106/L), of which 92% were monocytes. Autoimmune diseases related test including anti-nuclear antibodies, anti-dsDNA, anti-streptolysin, rheumatoid factor, thyroid function tests, erythrocyte sedimentation rate (ESR), and hypersensitive C-reactive protein were all negative. T cell spot tuberculosis (TB) testing was positive. No tubercula bacilli were found in sputum TB smear. Anti-TB antibodies of Lipoarabinomannan-IgG and 38 KD/IgG in the serum were positive. Quantitative detection of Brucella polymerase chain reaction was negative in the CSF. Brain MRI after admission demonstrated multiple patchy abnormal signal in pons, the right thalamus, the left basal ganglia, corona radiate and corpus callosum on fluid-attenuated inversion recovery (FLAIR) imaging, diffusion-weighted imaging (DWI), and T2-weighted (T2W) imaging (Fig. 2). The second MRI scan of cervical and thoracic spinal cord after admission to the hospital revealed hyperintensity lesions extending from C3 to T8 on T2W image, T1-weighted (T1W) image, and FLAIR image (Fig. 3A-C). Chest CT during hospitalization showed left lung upper lobe bronchiectasis and multiple calcifications of upper lobe in both sides (Fig. 3D). The patient was treated with methylprednisolone of 500 mg for 3 days, afterwards, the dose of methylprednisolone was decreased to half every 3 days, meanwhile she also received gamma globulin and anti-tuberculosis drugs (isonicotinyl hydrazide 0.3 g/d, rifampin 0.45 g/d, pyrazinamide 1 g/d, and ethambutol 1 g/d). The patient discharged from hospital after 1 months' treatment. The EDSS was decreased to 0 at the time point of follow up 12 months later. The spinal cord MRI showed the lesion size in the cervical and thoracic spine were significantly reduced (Fig. 4).
MRI scans of case 1 before treatment showed hyperintensity lesions in the spinal cord from C3 to T8 on T2 sequence Chest CT scan showed bronchitis and pneumonia in both sides, bronchiectasis in the left upper lobe and multiple calcifications of in both upper lobe (D). CT = computed tomography, MRI = magnetic resonance imaging.