Clinical Reasoning: Bacterial meningitis causing a neuromyelitis optica flare.

A previously healthy 49-year-old woman experienced left arm paresthesias. Over the next few weeks, the paresthesias progressed to all extremities. Initial laboratory studies were unrevealing; the patientu0027s progressive weakness and numbness continued. An MRI brain was consistent with an unspecified demyelinating disease affecting the cortical white matter and cervical spine. Lumbar puncture revealed normal cell count and differential, with negative culture, gram stain, and oligoclonal bands. She was then diagnosed clinically with multiple sclerosis (MS) and treated with teriflunomide. She soon developed skin and joint pain, intractable hiccups for 22 days, early satiety, and urinary incontinence. Repeat MRI again showed demyelinating lesions, this time in her thoracic spine. Her treatment was changed to glatiramer acetate.