Spinal cord glioblastoma is a rare tumor type constituting 1% to 5% of all glioblastomas and 1.5% of all the spinal cord tumors. More common in young men in second or third decade. We present a perplexing case of a 76-year-old male afflicted by longitudinally extensive transverse myelitis (LETM), culminating in a fatal outcome within a month of diagnosis.

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A 76 year old was with flaccid paraplegia for over 6 weeks, despite conventional treatment modalities such as intravenous immunoglobulin (IVIG) and high-dose methylprednisolone, was transferred to our hospital for further evaluation. Clinical evaluation unveiled a sensory level extending up to T6, with magnetic resonance imaging (MRI) spine revealing intramedullary lesions in the cervical and thoracic regions, accompanied by nodular dural enhancement along the thoracic cord.  CSF studies revealed 32 WBC, protien 280 mg/dl, glucose 10 mg/dl, no malignant cells, negative VDRL, ACE, meningoencephalitis and autoimmune panel including MOG and NMO antibodies. CT chest, abdomen and pelvis was negative for malignancy. He was started on plasmapheresis for 5 cycles. The clinical trajectory took an unexpected turn as the patient developed ophthalmoplegia, ptosis of the right eye, bilateral eye closure weakness, arm weakness, and thigh muscle fasciculations. MRI imaging delineated involvement of bilateral cranial nerves (5th and 7th), alongside extra-dural enhancement in the right temporal region. Whole-body positron emission tomography (PET) further unraveled heightened signal in the thoracic cord, prompting neurosurgical intervention. A dural biopsy from the thoracic region unmasked a sinister entity - a spindle cell neoplasm exhibiting molecular features akin to glioblastoma, with wild-type isocitrate dehydrogenase (IDH). Unfortunately, he succumbed to the illness within 2 weeks of the diagnosis.                         

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This captivating case underscores the paramount importance of vigilance in the face of diagnostic uncertainty, showcasing the elusive nature of glioblastoma masquerading as longitudinally extensive transverse myelitis.