Coxsackie B3/B4-Related Acute Flaccid Myelitis

Excerpt

A 36-year-old healthy man presented with headache, neck stiffness, photophobia, confusion, and flaccid paraplegia 10 days after a developing fever, sore throat, and rhinorrhea. A MRI of the spine demonstrated a non-enhancing central cord lesion extending from C6-T12 (Fig. 1). Gadolinium-enhanced MRI of the brain was normal. Cerebrospinal fluid (CSF) evaluation revealed 203 red blood cells (RBCs)/µL, 214 white blood cells (WBCs)/µL (95% lymphocytes), 143 mg/dL protein, and 46 mg/dL glucose (95 mg/dL serum glucose). Extensive serum and CSF evaluation for infection, inflammation, and malignancy were negative including testing for HIV-1/2, herpes simplex virus, varicella-zoster virus, Epstein–Barr virus, cytomegalovirus, West Nile virus, syphilis, enterovirus polymerase chain reaction (PCR), Lyme, neuromyelitis optica (NMO) antibody, angiotensin converting enzyme (ACE), paraneoplastic antibodies cytology, cryptococcus, and CSF bacterial and fungal cultures. Transbronchial lymph node biopsy was negative for sarcoid and malignancy. Increases in acute and convalescent serum Coxsackie B3 (1:160 to ≥1:640) and B4 (1:320 to ≥1:640) antibody titers over 27 days indicated recent Coxsackie infection. The patient was treated with 1 g of methylprednisolone for 5 days, followed by five sessions of plasmapheresis with clinical and radiographic improvement. At 3-month follow-up, he was ambulatory with 4+/5 lower extremity strength.

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