Intractable Nausea and Vomiting: A Key Feature of Neuromyelitis Optica Spectrum Disorder.
Jasmine M Silva, Jorim Parmar, Shivani Gandhi et al.
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Case in brief
A 22-year-old woman had five weeks of intractable nausea, vomiting, and hiccups. Delayed gastric emptying led to an initial diagnosis of gastroparesis, but symptoms persisted despite antiemetic and prokinetic therapy. On readmission, persistent hiccups and progressive bilateral arm weakness prompted MRI, which showed an expansile T2-hyperintense lesion in the dorsal lower medulla and upper cervical cord. Serum AQP4-IgG was positive, establishing NMOSD with area postrema syndrome. She received high-dose intravenous corticosteroids and seven plasma exchange sessions, followed by rehabilitation; motor function improved and she regained ambulation with a walker.
What made this case unusual
The gastrointestinal symptoms and hiccups preceded the progressive limb weakness, and delayed gastric emptying initially supported a misleading diagnosis of gastroparesis.
Diagnostic / clinical pearl
Persistent unexplained nausea, vomiting, or hiccups can reflect area postrema syndrome in NMOSD. In this case, medullary and upper cervical cord MRI findings and positive serum AQP4-IgG clarified the diagnosis.