Acute Hemorrhagic Myelitis Presenting as Hyperacute Quadriparesis with Respiratory Failure: A Spinal Cord Emergency

Abstract

Hemorrhagic myelitis is a rare and severe inflammatory disorder of the spinal cord characterized by hemorrhagic necrosis and rapid neurological deterioration. We report a 55-year-old woman who presented with acute onset neck pain followed within hours by rapidly progressive quadriparesis, sensory loss below the neck, truncal weakness, and respiratory failure requiring mechanical ventilation. She had antecedent episodes of fever associated with bifrontal headache and left cervical swelling 2 months before neurological illness. Neurological examination showed flaccid quadriplegia, areflexia, sensory level below C5, impaired joint position sense, truncal and neck weakness, and no higher mental functions and cranial nerve involvement. Magnetic resonance imaging (MRI) of the spine demonstrated a long segment hemorrhagic intramedullary lesion extending from C2 to D4 with cord expansion and diffusion restriction suggestive of hemorrhagic myelitis. MRI of the brain revealed a right parietal hemorrhage. Cerebrospinal fluid (CSF) examination revealed hemorrhagic CSF with elevated protein levels and negative results for bacterial, mycobacterial, and viral studies. Autoimmune and demyelinating workup, including neuromyelitis optica and myelin oligodendrocyte glycoprotein antibodies, was negative. A diagnosis of acute hemorrhagic myelitis was considered after exclusion of infective, autoimmune, and demyelinating etiologies. This case highlights the importance of recognizing hemorrhagic myelitis as a rare cause of hyperacute myelopathy with respiratory failure.