A 59-year-old African American male developed acute onset of back pain shortly after lifting heavy boxes followed by four days of progressive weakness, sensory loss, saddle anesthesia, and urinary incontinence. Exam showed bilateral lower extremity weakness and numbness (right > left, distal > proximal), hyperreflexia in the upper extremities, absent Achilles and right patellar reflexes, with mute plantars.  

MRI revealed a T2 hyperintense lesion extending from T11 to the conus medullaris with central cord predominance, without enhancement. Restricted diffusion was seen at the same level. No other lesions were noted throughout the neuroaxis.  CSF demonstrated pleocytosis (>400 cells, neutrophil-predominant), elevated IgG index (0.78), and negative autoimmune, infectious, and MOG/NMO antibody panels. CSF MOG is currently pending.  After ruling out infectious causes, intravenous methylprednisolone was administered for seven days with mild improvement, followed by plasma exchange for five days, resulting in a more robust clinical recovery.