A 64-year-old man presented to the emergency department with a one-day history of lower extremities distal numbness, rapidly progressing to four-limb weakness, back pain, dysarthria, facial weakness, and diplopia. He had received influenza vaccination 18 days before. Five days after vaccination, the patient developed productive cough and diarrhea lasting 3 days. Initial neurological evaluation disclosed marked leg (1/5 grade) and mild arm weakness (4/5 grade), hypoactive deep tendon reflexes, normal plantar reflexes, decreased pinprick, and vibration sensation in all limbs, without a well-defined sensory level, as well as bilateral facial weakness, dysphonia, dysphagia, and restricted eye movements in all directions. The patient quickly developed urinary retention, labile blood pressure, and respiratory distress, ultimately requiring ventilatory support. Brain computed tomography results were normal. Cerebrospinal fluid (CSF) analysis revealed 1 leukocyte/mm3, high protein content (763 g/dl), normal glucose level, and negative bacteriological testing. Guillain-Barre syndrome was suspected, and the patient was treated with intravenous immunoglobulin (0.4 mg/kg/d) for 5 days. Electrodiagnostic studies showed decreased motor and sensory potentials, mild slowing of nerve conduction, and denervation signs in all limbs, consistent with an acute axonal motor sensory polyneuropathy, with a markedly predominant motor impairment. Upper limb strength, facial weakness, and eye movements gradually improved. On hospital day 55, the patient no longer required ventilatory support but still experienced urinary retention and bilateral leg anesthesia. A defined T8 sensory level became apparent. A spinal cord MRI showed a longitudinally tumefactive spinal lesion extending from T6 to the cone (Figure 1). Repeat CSF analysis showed increased cell count (31 leukocytes/mm3), elevated protein levels (1,722 g/dl), and high gamma globulin levels (29.9%, range 7-14%). CSF polymerase chain reactions (PCR) for Mycobacterium tuberculosis, Herpes simplex (HSV) I/II, cytomegalovirus, Epstein-Barr (EBV), and varicella-zoster viruses were negative. Serological testing did not indicate recent or active Borrelia, Bartonella, EBV, HSV I/II, HIV, HTLV, syphilis, hepatitis, or Mycoplasma pneumoniae infection. Serum anti-aquaporin-4 and rheumatological tests were negative.
The patient was treated with a 5-day methylprednisolone course (1 g/day), 1 g cyclophosphamide, and six plasma exchange sessions, without lower limb strength or sensation improvement. Additionally, the patient received a 14-day doxycycline course, due to positive Mycoplasma serum IgG titers and the history of productive cough. The patient was discharged to long-term rehabilitation on hospital day 170, still unable to walk, on intermittent bladder catheterization.