Fibrocartilaginous embolism (suspected)
A 17 years old female athlete who just recently had a marathon race was on a plane traveling from Chicago to Miami. She had no significant past medical history. Just few minutes before landing she developed sudden onset pain in the posterior aspect of her left shoulder. Then she developed pain and paresthesia in entire left upper extremity followed by left lower extremity. After few minutes while she was on the airport she experienced weakness on the left side of her body. By the next two hours she noticed the same pattern emerging on the right side of her body and within two more hours she found herself in a quadriplegic state. She also complained of nuchal pain 3/10 intensity. On initial examination she was alert and oriented with no cognitive impairment. Cranial nerves were intact with 5/5 strength in trapezius and sternocleidomastoid. Her voice was weak, coughing was ineffective and she had mild difficulty breathing. Muscle strength was 0/5 bilaterally in all extremities. Sensations were globally reduced in all limbs, but pain and temperature sense was more preserved on left side while vibration and proprioception was more preserved on the right side. Deep tendon reflexes were absent throughout except for +2 right knee jerk. Plantar reflex was absent bilaterally. CT scan & MRI brain was performed soon which returned normal. CSF analysis was within normal limits. T2-weighted MRI cervical spine done 6 hours after initial symptoms revealed minimally increased T2 signal in the central gray matter at the level of C5-C6-C7. Repeat MRI cervical spine was done 3 days later.
MRI cervical spine: 3 days after initial presentation
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Hyperintense T2 signal between C2-T2 level indicates severe spinal cord inflammation or infarction. In addition, there's decreased signal at C5-C6 intervertebral disc. These findings may point towards possible fibrocartilaginous embolism.
This case is dramatic and the imaging appearances suggested the differential diagnosis of fibrocartilaginous embolism or transverse myelitis. To treat the later IV methylprednisone was administered. IV acyclovir was also being given to cover a possible viral etiology.
Unfortunately no clinical improvement was noticed after 5 days of steroid treatment.