106 Post-traumatic neuromyelitis optica spectrum disorder

Abstract

IntroductionNeuromyelitis optica spectrum disorders (NMOSDs) are immune-mediated demyelinating disorders affecting the brain and spinal cord. There are case-series of post-traumatic multiple sclerosis, but only one case-report previously of post-traumatic neuromyelitis optica.CaseA 57 year old man presented to hospital following a fall down two flights of stairs while intoxicated, and was found on CT to have small bi-frontal subdural haematomas, traumatic subarachnoid haemorrhage, bilateral occipital contusions, and non-displaced fractures through the right parietal bone and bilateral petrous temporal bones. While agitated, he developed subacute onset of visual loss and paraplegia at day 22. An MRI spine at day 12 showed only degenerative changes. However a repeat MRI brain and spine at day 26 revealed enhancing longitudinally extensive optic nerve lesions, indicative of optic neuritis and an extensive segment of intramedullary enhancement within the mid to lower thoracic cord, consistent with longitudinally extensive transverse myelitis. A CSF sample revealed raised protein (9.81 g/L), elevated lactate (3.54 mmol/L), 1 red cell, 41 monocytes. CSF oligoclonal bands, aquaporin 4 antibodies, MOG antibodies, anti-neuronal antibodies and ACE were negative. Serum anti-neuronal antibodies, HTLV-1 and 2 serology, ANA, ENA, ACE, MOG and aquaporin 4 antibodies were also negative. Treatment with iv methylprednisolone, plasma exchange and mycophenolate led to recovery of gait at 2 months and ability to drive by 1 year. Patient remains stable at 2 year follow-up.ConclusionWe report a case of bilateral optic neuritis and longitudinally extensive thoracic transverse myelitis following a traumatic brain injury. The presentation was consistent with an NMOSD and the patient responded to immunomodulatory therapy. The hypothesis is that the traumatic brain injury led to a defect in the blood brain barrier, allowing autoantibodies to enter the CNS and incite inflammation.