Neuromyelitis Optica Spectrum Disorder Presenting as Cervicothoracic Longitudinally Extensive Transverse Myelitis in a Patient with Advanced Chronic Kidney Disease

Abstract

Aims: To present the diagnostic differentiation and multidisciplinary neuro-renal nursing management of a rare, life-threatening presentation of Neuromyelitis Optica Spectrum Disorder (NMOSD) complicated by advanced Stage 4 chronic kidney disease (CKD). Presentation of Case: A 42-year-old female with known Stage 4 CKD presented with a 5-day history of progressive asymmetric quadriparesis, absolute urinary retention, a T4 sensory level, and Class C/D lethargy progressing to respiratory compromise. Spinal magnetic resonance imaging (MRI) revealed a longitudinally extensive transverse myelitis (LETM) lesion spanning C4 to T8. Brain MRI showed periependymal lesions around the third ventricle and area postrema. Serological testing confirmed a strongly positive result for anti-aquaporin-4 antibodies (AQP4-IgG). Laboratory findings confirmed advanced renal failure (serum creatinine: 3.8 mg/dL, blood urea: 82 mg/dL, eGFR: 18 mL/min/1.73m²). The patient was treated with high-dose intravenous methylprednisolone (1 g/day for 5 days) alongside five cycles of therapeutic plasma exchange (PLEX). Comprehensive, targeted neuro-renal nursing interventions addressed airway preservation, fluid restriction, avoidance of systemic risks, and neurogenic bladder care. Following therapy, her sensorium normalised completely, and motor strength improved to 4/5 in all extremities. Discussion: NMOSD should be considered in patients presenting with acute longitudinally extensive transverse myelitis and altered sensorium, particularly when MRI findings and AQP4-IgG serology support the diagnosis. Coexisting advanced CKD may complicate both diagnosis and treatment, requiring individualised management strategies. Conclusion: Early recognition of NMOSD, prompt initiation of immunotherapy, and multidisciplinary neuro-nephrology care can improve neurological outcomes even in critically ill patients with advanced CKD.