A 12-year-old girl presented for assessment of abnormal gait. A year prior, she was found to have bilateral panuveitis with occlusive retinal periphlebitis involving all quadrants of the central and peripheral retina with capillary nonperfusion (Figure 1). Her subsequent workup revealed elevated inflammatory markers and subcentimeter chest and abdominal lymph nodes. Given a positive interferon-γ release assay, therapy was initiated with rifampin, isoniazid, pyrazinamide, ethambutol (RIPE) and corticosteroids for presumed tuberculosis.
At the time of presentation, she had completed RIPE therapy and was taking mycophenolate mofetil with resolution of her ocular manifestations. She complained of new bilateral lower extremity weakness with associated lower back pain. Clinical examination results revealed a wide-based Trendelenburg gait with right foot drop and diminished strength of lower extremity flexors. Laboratory testing results showed a normal white blood cell count, vitamin B12, angiotensin-converting enzyme, lysozyme, C-reactive protein, and antinuclear antibody levels. She had negative test results for Lyme disease, syphilis, and HIV. Computed tomography showed small supraclavicular and mediastinal lymph nodes and an enlarged spleen. Magnetic resonance imaging demonstrated mild lacrimal gland prominence and low thoracic/high lumbar spine and cauda equina nerve roots hyperintensity and abnormal enhancement. Cerebrospinal fluid analysis revealed a lymphocytic pleocytosis with an elevated protein level, negative syphilis antibody results, and an absence of organisms on acid-fast bacilli smear, Gram stain, and culture.