Disclosures: Elisa M. Chiu, DO: No financial relationships or conflicts of interest

Case Description: A 47-year-old female with history of systemic lupus erythematosus (SLE) on prednisone presented to the hospital complaining of worsening bilateral lower extremity weakness. Physical exam revealed bilateral quadriceps atrophy, worsening bilateral weakness, and bilateral ankle clonus. Sensory exam revealed left leg numbness and right leg hyperesthesia. MRI showed diffuse atrophy of the cervical spinal cord extending to the conus medullaris. She was initially diagnosed with Brown-Sequard syndrome secondary to SLE. She was weaned off steroids, started on mycophenolic acid (MMF) and hydroxychloroquine, and admitted to acute inpatient rehabilitation.

Setting: Academic Inpatient Rehabilitation Hospital

Patient: 47-year-old female presenting with worsening bilateral lower extremity weakness and sensory deficits Assessment/

Results: In acute rehabilitation, ESR remained persistently elevated, despite immunosuppressive therapy. When MMF dose was increased, she developed neutropenia, and immunosuppressants were discontinued. She continued to make functional improvements despite stopping treatments, prompting further rheumatologic evaluation. Workup revealed positive aquaporin-4 receptor antibody, diagnostic of neuromyelitis optica spectrum disorders (NMOSD). At time of presentation, she required total assistance for transfers and dependent for standing. Upon discharge, she required close supervision for transfers and moderate assistance in parallel bars.

Discussion: NMOSD are inflammatory disorders of the central nervous system characterized by severe, immune-mediated demyelination and axonal damage, predominantly targeting the spinal cord and optic nerves. NMOSD is frequently associated with autoimmune disorders such as SLE. Hallmark features include acute attacks of optic neuritis or transverse myelitis, associated with vision loss, eye pain, limb weakness, sensory loss, or bladder dysfunction. Interestingly, this patient did not have any optic complaints or findings, ultimately confounding the diagnosis of NMOSD.

Conclusion: NMOSD may not always present with optic findings. In patients with symptoms mimicking optic neuritis or transverse myelitis, NMOSD should be considered. For patients with NMOSD, early diagnosis and intervention with high-dose steroids and acute rehabilitation are crucial for functional recovery after an acute attack.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/complex-diagnosis-of-neuromyelitis-optica-with-no-optic-findings-a-case-report/