A case of SLE presenting with acute haemorrhagic longitudinally extensive transverse myelitis

<h3></h3> A 54-year-old Ghanaian woman with a history of chronic back pain and sciatica presented with acute severe lower radicular pain followed by flaccid areflexic paraplegia, T9 sensory level and urinary retention. Weakness reached nadir within 3 hours of pain onset. Magnetic resonance imaging demonstrated complete cross sectional spinal cord oedema from T9 to the conus, with small foci of intramedullary haemorrhage. There was lumbosacral nerve root enhancement. Laboratory investigations revealed strongly positive ANA, Anti-Ro, and Anti- Smith antibodies in keeping with a new diagnosis of systemic lupus erythematosus (SLE). Cerebrospinal fluid showed raised protein and mild predominantly neutrophilic pleocytosis. Further assessment revealed long standing arthralgia of the feet with no signs of active inflammation on examination. There was no other organ involvement from SLE, and no other cause of LETM was identified. Transverse myelitis is a rare (0.5% to 1%) complication of SLE. Acute haemorrhagic LETM is exceedingly more uncommon, reported in only a handful of cases. Unlike typical inflammatory myelitis, it has a hyperacute onset more evocative of a vascular event and a medically refractory course. This unique case alerts neurologists to a rare presentation and also highlights the importance of detailed radiological and laboratory evaluation of such cases.