A forty year old previously healthy Sri Lankan male presented with acute onset bilateral leg weakness which was progressive over two days following a brief febrile illness of three days. He did not give any history of trauma nor there was any history of tuberculosis. Initially he did not have urinary retention nor there was any sensory symptoms. He did not complain of shortness of breathing.\nOn examination he was found to have asymmetric flaccid paralysis of bilateral lower limbs with power grade one to two. Reflexes were diminished bilaterally and Babinski sign was equivocal. Examination of optic fundi and cranial nerves were normal. There was no demonstrable sensory level and joint position sense was initially preserved. Upper limbs were neurologically normal. Respiratory movements and sphincter function were preserved. Depending on initial findings a clinical diagnosis of Guillain-Barré syndrome was suspected and he was closely observed for the development of respiratory paralysis with monitoring of forced vital capacity and oxygen saturation.\nOn the fifth day of onset of symptoms his weakness worsened with additional flaccid paralysis of upper limbs and neck muscles. He was catheterized for acute retention of urine. Patient was urgently transferred to a high dependency unit but he did not develop respiratory paralysis necessitating ventilator support. Later he developed bilateral spastic paraparesis and positive Babinski sign with mild paraesthesia of lower limbs. But he did not develop a definite sensory level at anytime during the course of his illness.\nA nerve conduction study failed to show demyelination or axonal loss. Magnetic resonance imaging study of the spine showed hyperintensity of central portion of mid cervical cord from C 2 to C 5 level in T2 weighted and FLAIR images (Figure \n) There was mild swelling of cervical cord without significant change of signal intensity on T1 weighted image (Figure \n).\nBasic investigations were as follows; Na+ 139 mmol/l, K+-4.2 mmol/l, Serum creatinine-62 μmol/l, blood urea 8.7 mmol/l, White cell count 5000/mm3(N-76,L-18), platelet count 17500/mm3. Haemoglobin 9.3 g/dl, AST-51u/l, ALT-74u/l, Bilirubin 12 μmol/l, ESR-12 mm/hr, CRP-0.4 mg/dl, VDRL-negative, Fasting blood sugar 5.4 mmol/l.\nCerebrospinal fluid analysis done on the tenth day after onset of weakness was suggestive of a viral CNS infection with a protein content of 300 mg/l, glcose 4.3 mmol/l(RBS 10.9 mmol/l) and a leukocyte count of 350/mm3(92% lymphocytes). CSF infectious screen was positive for cytomegalovirus PCR(sensitivity more than 100copies/ml). This test was repeated and result was confirmed. Cytomegalovirus IgG and IgM were not detected in CSF. Polymerase chain reaction of CSF for herpes simplex virus(HSV) and Japanese encephalitis virus(JEV) were negative. Oligoclonal bands were not detected in CSF.\nConsidering the overall clinical picture, a working diagnosis of CMV associated transverse myelitis was made. Immunoglobulin levels and lymphocyte subset analysis failed to identify any immunodeficiency while HIV serology was negative.\nPatient received treatment with intravenous ganciclovir for a duration of 21 days starting on the 10th day of illness. He was also given maximal supportive care with physiotherapy and psychological support. A second CSF analysis done 22 days after the onset of symptoms revealed no cells and protein content of 390 mg/l. (CSF glucose 3.6 mmol/l RBS-6.5 mmol/l) Repeated CMV serology in blood, CSF and CSF PCR for CMV were negative on the 22nd day of illness.\nOne month after the onset of symptoms the upper limb power was improved (grade 5) but the lower limb power remained grade 3. He was transferred to a long term rehabilitation facility.
A 29 years-old man was admitted to our neurological department with five months of progressive disability in walking, paresthesia in the arms when bending the neck, numbness in the hands, and back pain. He had been treated for many years with aerosol salbutamol during exacerbations of asthma. Apart from periodic jaw spasms during the last five years, there were no apparent previous illnesses and no suspicion of infection within the last six months. During the last two years, he had been successfully treated for his injectable drug abuse with daily oral methadone. The patient had had negative hepatitis C virus RNA (HCV) serology two years before presentation. The neurological examination revealed positive Lhermitte`s sign, hypoesthesia in the hands, normal muscle strength in the upper limbs, reduced muscle strength in the legs (4 on a MRC scale), and reduced dorsiflexion of the feet (4 on a MRC scale). In addition, the patient had severe increased spasticity in the extensor muscles of the lower limbs, bilateral-positive Babinski, and a broad-based gait requiring support.\nSpinal cord MRI demonstrated extensive longitudinal spinal cord lesions from the cervical vertebral segment C1 to C5 and thoracic vertebral segment T2 to T11 (Figure ). The cervical lesion was located in the dorsal part and over a short distance in the lateral part on the right side on T2-weighted images. Discrete enhancement was found in the posterior part. Changes in the thoracic part were seen almost over the cord's entire cross section on the T2-weighted images, but enhancement was only demonstrated in the lateral part on both sides. The brain MRI was normal.\nA lumbar puncture was performed with cerebrospinal fluid showing slight pleocytosis with 11 mononuclear cells, a slightly increased protein to 0.64 g/l, normal IgG index and no oligoclonal bands, no antibodies against the varicella-zoster virus, herpes virus, entero-virus, or borrelia. The blood tests showed normal B12 vitamin, rheumatoid factor IgM and ANA, negative HIV serology, negative syphilis RPR, negative TB gamma interferon release assay, negative MOG- and AQP-4 antibodies, and increased ALAT to 200 U/l. Tests for HCV serology and HCV RNA were both positive.\nTreatment of HCV infection with Zepatier (elbasvir 50 mg and grazoprevir 100 mg) one tablet daily was initiated and continued for three months. Follow-up blood tests showed normalization of ALAT, negative HCV serology, and normalization of the spinal cord changes on MRI. The neurological findings were unchanged. There was no clinical suspicion of rheumatic, vascular or skin diseases and normal thyroid, white blood cells and renal function tests. With that condition, we found no indication for steroid treatment also taking into account previous episodes of psychosis in relation to his drug abuse.\nDespite a four-week course of inpatient rehabilitation, the physical condition was only slightly improved. Currently (two years later), walking distance is reduced, a stick is required when walking outside, and medication is still necessary for spasticity and neuropathic pain in the legs.