Neuromyelitis optica with fluorosis: An association or coincidence

A 46 yr old female† presented to the Neurology Emergency department in the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India, with myelopathy, nausea and vomiting of two weeks duration in the month of October 2018. The patient had flexion deformities in upper limbs and thoracolumbar scoliosis with bulbar dysfunction, hypophonia and quadriparesis (power 0-–1/5). On evaluation, the patient was diagnosed as seropositive neuromyelitis optica (NMO) as neuroimaging features were characteristic (Fig. 1A and 1B). The patient was managed with intravenous steroids for five days, followed by oral steroids. In addition, there were ossification of the posterior longitudinal ligament (OPLL), interosseous membrane calcification (Fig. 2) and osteosclerosis of axial bones (Fig. 3), findings consistent with diagnosis of fluorosis, which is now rarely seen or underdiagnosed and can also present with compressive myelopathy, as in this patient adding to diagnostic confusion. She made minimal improvement with steroids and plasmapheresis and was on long long-term follow up. Prompt investigations helped in identifying the underlying dual pathology, avoidance of toxic immunomodulators and also in prognostication in this patient.

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Fig. 1

(A) Magnetic resonance imaging (MRI) spine sagittal T2 showing long-segment differential hyperintensities in central cervical cord involvement extending up to the medulla (arrow). (B) Axial MRI T2-weighted image showing bright T2 spotty lesion (arrow) characteristic of neuromyelitis optica.

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Fig. 2

X-ray of bilateral forearm showing calcification of interosseous membrane (arrow).

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Fig. 3

X-ray of spine anteroposterior and lateral views showing osteosclerosis of axial bones.

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