5th Edition of International Neurology Conference 2026

Abstract

Aquaporin-4 immunoglobulin G antibody (AQP4-IgG)-associated neuromyelitis optical spectrum disorder (NMOSD) is an uncommon autoimmune inflammatory disease in children that predominantly affects the optic nerves and spinal cord. Its initial manifestations may occasionally mimic central nervous system infections, creating a significant diagnostic challenge and potentially delaying immunotherapy. We present the case of a previously healthy 13-year-old boy who developed fever, severe headache, bilateral retro-orbital pain, vomiting, drowsiness, and meningeal signs. Cerebrospinal fluid analysis revealed marked pleocytosis of 690 cells/mm³, with a predominance of polymorphonuclear cells, preserved glucose levels, and mildly elevated protein. Bacterial cultures, Gram staining, and fungal studies were negative. Because he had received antibiotics before admission, partially treated bacterial meningitis or subacute meningitis was initially suspected, and antimicrobial therapy with ceftriaxone and vancomycin was initiated. Despite transient resolution of the fever, the headache, retro-orbital pain, and meningeal signs persisted. The patient subsequently developed recurrent fever, urinary retention, low back pain, gait impairment, sensory abnormalities, and rapidly progressive quadriparesis. Magnetic resonance imaging demonstrated optic nerve and optic chiasm involvement, together with longitudinally extensive transverse myelitis. Immunological testing detected serum AQP4-IgG antibodies, whereas antibodies against myelin oligodendrocyte glycoprotein were negative, confirming the diagnosis of AQP4-IgG-associated NMOSD. Positive IgM and SAMPLE ABSTRACT TEMPLATE IgG serology for Mycoplasma pneumoniae was also documented, suggesting a recent infection and raising the possibility of an infectious trigger. However, a direct causal relationship could not be established. The patient received high-dose intravenous methylprednisolone followed by maintenance immunotherapy, with progressive recovery of muscle strength, gait, and sensory function. This case illustrates the diagnostic complexity of a biphasic neurological illness in which an initial neuroinfection followed by secondary autoimmunity cannot be reliably distinguished from an autoimmune inflammatory disorder with an infection-like presentation. AQP4-IgGassociated NMOSD should be considered in children with an atypical or treatmentunresponsive meningeal syndrome who subsequently develop visual, spinal cord, or sphincter dysfunction. Early recognition and timely immunotherapy are essential to prevent permanent neurological disability.