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General Rehabilitation

When the Immune System Strikes Back: A Case of Neuromyelitis Optica

Thursday, October 23, 2025
5:00 PM - 6:30 PM MT
Location: Open Kiosks
Has Audio

    Primary Author(s)

  • Justin Wang, MD

    Resident Physician
    Nassau University Medical Center PM&R Program
    East Meadow, New York

    • Co-Author(s)

  • BF

    Brent Fogel, DO

    Resident
    Nassau University Medical Center PM&R Program
    Melville, New York

  • FB

    Forrest Butensky, DO

    Resident Physician
    Nassau University Medical Center PM&R Program
    Rockville Centre, New York

    • Poster Presenter(s)

  • Chi Lam Kwok, DO

    Resident
    Nassau University Medical Center PM&R Program
    Flushing, New York

    • Co-Author(s)

  • AS

    Ajendra Sohal, MD

    attending
    Nassau University Med Center
    Roslyn, New York

Disclosure(s):
Justin Wang, MD: No financial relationships to disclose
Brent Fogel, DO: No financial relationships to disclose
Forrest Butensky, DO: No financial relationships to disclose
Ajendra Sohal, MD: No financial relationships to disclose
Case Diagnosis: Neuromyelitis optica spectrum disorder

Case Description or Program Description: A 74 year old female with history of cerebrovascular accident presented with right sided weakness and left leg sensory deficits. Due to concern for stroke, the patient underwent MRI imaging. Patient received steroids without improvement. Patient was then started on rituximab and underwent acute rehabilitation which saw her strength gradually return.

Setting: Inpatient

Assessment/Results: MRI brain: no acute infarct. MRI cervical spine: diffuse hyperintense signal throughout C2-5. Lumbar puncture due to persistent weakness: negative antibodies against aquaporin-4 (AQP4-IgG).

Discussion (relevance): Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune disease that can affect the optic nerves and spinal cord, causing vision loss, paralysis, and other neurological symptoms in a typically relapsing course. It is often misdiagnosed as multiple sclerosis (MS) but differs in its pathophysiology and treatment, as well as the typical presence of AQP4-IgG. A diagnosis of NMOSD is made if AQP4-IgG is positive and at least one Core Clinical Characteristic (CCC) such as optic neuritis or acute myelitis is present. If AQP4-IgG is negative it can be diagnosed if at least two CCCs are present (with at least one being optic neuritis, acute myelitis, or area postrema syndrome), as well as supporting MRI findings. Treatment focuses on preventing relapses and managing acute attacks. Acute episodes are treated with high-dose corticosteroids. Long-term immunosuppressive therapies, including rituximab, help reduce relapse risk.

Conclusions: This case highlights the diagnostic complexity of AQP4-IgG-negative NMOSD, emphasizing the need for clinical suspicion even in atypical presentations. Despite initial concerns for stroke, MRI findings and persistent deficits guided further evaluation, leading to appropriate immunotherapy. The patient’s improvement with rituximab underscores the importance of early treatment. NMOSD remains a challenging diagnosis, particularly in seronegative cases, necessitating comprehensive clinical, imaging, and laboratory assessment. Prompt recognition, immunosuppressants, and physical rehabilitation are crucial in preventing long-term disability and improving patient outcomes.