Clinical recovery in a patient of Neuromyelitis Optica with Spinal Cord Atrophy- A Case Report

Neuromyelitis Optica (NMO) spectrum disorder is a chronically relapsing autoimmune astro-cytopathy mainly affecting optic nerve, spinal cord and brain stem. With newer treatment modalities, the clinical course of the disease has changed significantly. Our patient, 30-year-old female first presented in Jan 2023, with low back pain and numbness below the level of umbilicus followed by weakness of the lower limbs over the period of 7 days. She also complained of bladder and bowel incontinence, besides there were no cranial nerve or upper limb involvement. Patient’s Magnetic Resonance scan (MR Scan) suggestive of patchy T2 hyperintense signals from thoracic vertebral level D3-D9 with myelomalacia. She had previous 3 attacks of acute myelitis in the years 2012,2017 and 2018. Her cerebrospinal fluid study was positive for Aquaporin 4 antibody, confirming the diagnosis NMO in 2012. She showed clinical improvement with steroids and tab Azathioprine. Patient had relapse in 2017 & 2018, for which she received 5 and 4 cycles of plasma exchange therapy respectively with significant improvement. Due to earlier response to steroids, patient was started on Injection Methyl Prednisolone with minimal improvement. Hence, patient was given 5 cycles of Plasma Exchange with high clinical suspicion of recovery. She responded to the extent that she was able to walk with support by day 15. However, repeat MR scan suggestive of persistent spinal cord atrophy. In summary, with high clinical suspicion and timely intervention with plasma exchange therapy in Neuromyelitis Optica, patient can have clinical improvement even in spinal cord atrophy.