To describe an adult-onset case of transverse myelitis associated with enterovirus (Coxsackie B5) infection.

Both Acute Flaccid Myelitis (AFM) and longitudinally-extensive transverse myelitis (LETM) are more commonly associated with pediatric enteroviral infections than adult infections. However, we present an adult case of AFM due to Coxsackie B5 virus with an atypical pattern on spinal imaging.

A 55-year-old male presented with acute urinary retention and lower extremity flaccid paraplegia two weeks after gastrointestinal illness. Neurologic exam revealed flaccid paralysis of bilateral lower extremities with absent lower extremity reflexes, and a sensory level to pinprick at T5. Vibration was diminished up to the ankle and proprioception was absent at the toes bilaterally.  MRI thoracic spine showed T2 hyperintensity of ventral and bilateral lateral columns spanning T4-T10 levels, with notable sparing of central gray matter. MRI brain revealed four periventricular and subcortical T2/FLAIR hyperintense lesions as well as one cortical lesion. Cerebrospinal Fluid (CSF) studies demonstrated 16 WBC, 63 Glucose, and 56 Protein with one unique oligoclonal band. CSF PCR panel was positive for Enterovirus Coxsackie B5. Of note spinal angiogram, NMO, MOG, other rheumatologic and infectious usual myelitis workup was negative. The patient was treated with two days of IV steroids, five days of IV immunoglobulin therapy (IVIG), and five PLEX sessions with minimal improvement.

We describe an adult patient presenting with Coxsackie B5-associated AFM with LETM. This patient demonstrated atypical MRI findings of T2 hyperintensity of the ventral and bilateral lateral columns spanning T4-T10 with notable sparing of central gray matter along with abnormal EMG suggesting anterior horn cell involvement. This case report highlights the importance of consideration of enterovirus as an etiology of atypical AFM with LETM in the adult population.