Case Report:
We report the case of a 28 year-old male patient without any medical history, who presented to emergency room with eye pain and blurred vision, gait disorders and dysuria.
He also reported a progressive and profound alteration of the general state with fever, and low abundance hemoptysis. In our department, the progression has been towards complete urine retention with the setup of a spastic paraplegia in few days.
Brain and spinal cord Magnetic Resonance Imaging (MRI) was performed, which revealed a cervio-dorsal transversal myelitis extended from C5 to T10 (figure 1) with optic nerve and optic chiasma contrast recording. The lumbar puncture showed a clear cerebrospinal fluid (CSF) with albumin-cytorrachiac dissociation (White Blood Cell (WBC) count of 7/mm3), elevated protein concentration (3.23 g/l; normal < 0.45 g/l) and low glycorrhachia (ratio of 1/3).
Direct examination and CSF culture were defective. Detection of Herpes Simplex Virus (HSV), Varicella Zoster Virus (VZV), enteroviruses,Listeria monocytogenes and Mycobacterium tuberculosis by Polymerase Chain Reaction (PCR) technique in the CSF was negative. Anti-NMO or anti-aquaporin 4 (AQP4) antibodies in the CSF was positive.
Ophthalmological examination showed the presence of bilateral papillary edema. Visual-evoked potential indicated a significant prolongation of the latency of the P100 wave.
Chest X-ray showed a bilateral micronodular infiltrate (figure 2) . A thoracic Computed Tomography (CT) scan revealed multiple lung injuries with bilateral acinar nodes, prevailing in the upper left lobe area associated with several cavitary lesions.
Tuberculin skin test (TST/Mantoux) was negative. Direct examination of the sputum did not reveal any acid-resistant bacillus (ARB). Pulmonary tuberculosis was diagnosed via endotracheal aspirate culture results.Mycobacterium tuberculosis was found in the culture. HIV serology was negative.
The diagnosis of Devic’s syndrome was based on the criteria of Wingerchuk and al (1) revealing associated pulmonary tuberculosis. Parenteral corticosteroid therapy was prescribed with immunoglobulins. Anti-tubercular therapy (ATT) was associated for 6 months. The outcome was only partially favorable with persistent paraplegia.