History A 31 year old Sri Lankan male who was recently discharged from
hospital with the diagnosis of transverse myelitis, got admitted to the casualty ward with rapidly progressing flaccid quadriparesis and bulbar involvement over last 3 days.
His weakness of bilateral lower limbs started on the 21st of July 2019(which
was the 10th postoperative day following an appendectomy) and it was
The weakness was more marked on left side and he tripped off while walking.He was conscious and afebrile. He had urinary retention, but there was no faecal incontinence. He denied having sensory symptoms back then. According to previous records he had bilateral spastic paraparesis (evident by power of left lower limb being 0, and right lower limb being 2 with bilateral up going plantar reflexes) without a sensory level, saddle anaesthesia or spinal tenderness. Anal sphincter tone was normal.
Examination of his upper limbs, cranial nerves and cerebellum were clinically normal. He was investigated in a medical unit where the diagnosis of transverse myelitis was made based on his clinical presentation and MRI findings which demonstrated transverse myelitis
involving 4th to 7th segment of spinal cord. He was referred to the neurology team who started him on IV methylprednisolone pulse therapy, physiotherapy and referred for rehabilitation after starting on oral prednisolone 1mg/kg. His muscle power improved significantly up to 4. Aetiology for transverse myelitis was not identified.
Unfortunately, following discharge the patient defaulted and presented again with worsening of neurology with weakness of all 4 limbs, dysarthria,
dysphagia, sialorrhoea and weakness of neck muscles. Breathing was normal.He has lost his bladder and bowel control.
On inquiry he had an abdominal pain unrelated to meals for last 2 months and constitutional symptoms. He was anorexic and lost 3 kgs during last month. He also had a low grade intermittent fever during that period. He had a transient, non pruritic rash over bilateral legs. He didn’t have active symptoms or signs of joint inflammation but had arthritis of his right knee joint following a sore throat a month ago and was diagnosed as having reactive arthritis. He denied having urinary symptoms, genitourinary discharges, gross haematuria or dark urine. He didn’t have photosensitivity, facial rash suggestive of malar rash or alopecia. He denied having red eyes, genital or oral ulcers.
His bowel habits were normal. He didn’t have cough, rhinorrhoea or a
headache suggesting sinusitis. There was no history of trauma, or features of increased intracranial pressure such as headache or vomiting.
According to the diagnosis card of his last hospital admission, he was admitted to hospital with severe central abdominal pain. USS showed inflamed appendix which was excised and sent for histology.
His past medical history revealed young hypertension (assessed and no
secondary causes identified), for which he was on nifedipine 20mg bd for last 6 months.He didn’t undergo any surgeries apart from the recent appendectomy. There were no neurological conditions in the family. He denied any allergies. He was a non-vegetarian, non-smoker and a social drinker.