Present a case of lupus myelitis occurring in a patient already receiving immunosuppression.

Neurologic complications of systemic lupus erythematosus span the central and peripheral nervous systems. We present a case of lupus myelitis in a patient previously well controlled with immunosuppression.

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A 24-year-old woman with history of systemic lupus erythematosus presented with acute onset inability to walk due to bilateral leg weakness and numbness, associated with constipation and urinary retention. A week before, she experienced runny nose, sore throat, headache and neck pain radiating down her shoulders. Her medication regimen prior to admission included mycophenolate mofetil 1500 mg BID, hydroxychloroquine 200 mg daily, and prednisone 2.5 mg daily.

Examination revealed bilateral lower limb weakness, more pronounced on right, hyperesthesia in the right leg, decreased proprioception bilaterally. She had intact pinprick, light touch, and vibration sense. Ankle reflexes were absent bilaterally.

Laboratory testing showed pancytopenia, elevated anti-DsDNA (107 IU/mL), ESR of 69 mm/h, low serum C3/C4 and proteinuria. COVID-19 testing was negative. CSF analysis showed WBC of 890/mm³, neutrophil predominance (93%), decreased glucose (32 mg/dL) and elevated protein (129 g/L). CSF cultures were negative. Aquaporin-4 receptor antibodies testing is pending.

MRI of thoracic spine revealed patchy FLAIR hyperintensities at the level of T2, T4 and T10-T11 with mild enhancement at the level of the lesion T10-11, following intravenous gadolinium.

The patient was treated IV methylprednisolone followed by cyclophosphamide and maintenance daily oral steroids with significant improvement of motor symptoms. She had mild residual right dorsiflexion weakness. Urinary and bowel function normalized.

Lupus myelitis is a rare and potentially devastating complication of systemic lupus erythematosus. The timely recognition is crucial for proper management. CSF picture resembles an infection and may be misleading. While aquaporin-4 receptor antibodies report is pending, her very good recovery with methylprednisolone and cyclophosphamide strongly suggests lupus myelitis.