A sixty-year-old male presented to the emergency department with complaints of subacute worsening shortness of breath, chest pain, and hypoxemia. He was found to have bilateral pulmonary infiltrates and was treated with Rocephin and Zithromax. Neurology was consulted for progressive paraparesis with sensory loss, urinary retention, and constipation. On initial physical exam, patient had mild bilateral lower extremity weakness with intact deep tendon reflexes (DTR). His exam progressively worsened over three days and later revealed more pronounced weakness with 2/5 motor strength in bilateral lower extremities. His DTRs were decreased to 1+ in bilateral patellae and absent in bilateral ankles. Pan-spine magnetic resonance imaging (MRI) demonstrated cord signal changes from cervical spine level 6 through thoracic spine level 9. Cerebrospinal fluid analysis showed: 152 protein, 68 glucose, and 14 white blood cells with lymphocytic predominance. Nerve conduction studies (NCS) showed evidence of patchy demyelinating sensory motor peripheral polyneuropathy with distal denervation in lower extremities concerning for acute inflammatory demyelinating polyneuropathy (AIDP). Neuromyelitis Optica/Aquaporin-4 (NMO/AQP4) antibodies were positive. He was treated with high dose steroid for 5 days and later received intravenous immunoglobulin (IVIG) with minimal
improvement. The patient was discharged to an acute rehabilitation facility for aggressive physical therapy.