Nancy Gilchrist , MD Children’s National Medical Center

Case: 3 yo female with new onset weakness 10 days after a URI which was complicated by an AOM and currently taking amoxicillin. Neurologic exam revealed normal reflexes but an abnormal gait and motor asymmetry.

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Discussion:

This case is a perfect case to bring light to the increasing epidemic of Acute Flaccid Myelitis (AFM). There are many resources the CDC provides to update families as well practitioners. Although this was not ultimately felt to be consistent with AFM, it does reveal some of the variations in potential management of a similar disease.

Fellows and attendings were split amongst starting with hip imaging, although, many felt the pathology was neurologic rather than MSK and thus requested an MRI. As stated by Dr. Agrawal, Ward, and others the MRI will be key in this patient but does it need to happen prior to admission to neurology. This is a very institutionally dependent situation so will inherently vary across the nation. Nonetheless, nearly everyone felt that despite it being the middle of the night neurology needs to be aware (for multiple reasons). Emergent MRI approval, admission to their service, and to broaden the differential.

Denouement:

Neurology was consulted and evaluated the patient in the ED. The patient was noted to have 4/5 strength in LLE concerning more for transient synovitis vs osteomyelitis. She was admitted for a MRI of her spine. The MRI was noted to have polyradiculitis of the lumbar motor nerves and myelitis of the lower spinal cord. CSF studies were unremarkable and the patient was treated with IVIG and then CTX for potential transverse myelitis secondary to Lyme (Lyme Western blot negative though this was noted after treatment and CSF for Lyme was negative).

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