In 2003, our patient experienced decreased sensation from the level of her mid chest down with coinciding urinary retention. She was found to have transverse myelitis at that time and underwent treatment with steroids with subsequent resolution. She followed with neurology for the next several years, undergoing serial imaging without any progression of disease. She continued to remain asymptomatic until 21 years later when she presented to our facility with mild, persistent paresthesias and intermittent double vision. Imaging demonstrated new T2 hyperintensities of the left lateral medulla, right paramedian pons, cervical spinal cord, and thoracic spinal cord. Given mild symptoms, plan was to follow-up in the neurology clinic within 2 weeks. MOG IgG antibodies returned positive (1:100) after her discharge but she presented 7 days later with clinical and radiographic worsening. She then underwent treatment with steroids and plasma exchange with eventual symptom resolution within 3 months.