A fulminant neuromyelitis optica spectrum disorder (NMOSD) Presenting with continued area postrema syndrome after COVID-19 infection: a case report

Area postrema syndrome, characterized by unexplained intractable nausea, frequent vomiting, and hiccups, serves as a hallmark feature of neuromyelitis optica spectrum disorder (NMOSD), often indicative of brain involvement. We report a case of a 26-year-old woman who, following recovery from a recent COVID-19 infection, endured persistent nausea and vomiting for 10 days. Subsequently, she presented to the emergency department with acute bilateral lower limb weakness and urinary retention. Brain magnetic resonance imaging (MRI) revealed hyperintense lesions in the area postrema on T2-weighted imaging, while spinal cord MRI demonstrated long-segment hyperintense lesions from the C2 to T12 levels on T2-weighted imaging. Cerebrospinal fluid analysis showed pleocytosis and elevated protein levels, alongside the presence of positive AQP-4 antibodies in the serum, confirming the diagnosis of NMOSD. Treatment comprising plasma exchange, pulse steroid therapy, and subsequent intravenous immunoglobulin administration led to notable improvement in bladder control and muscle strength. Our case underscores the significance of recognizing area postrema involvement, even in patients with post-COVID-19 symptoms, and highlights the necessity for vigilance in diagnosing NMOSD, particularly when initial symptoms mimic gastrointestinal discomfort.