title: Seronegative neuromyelitis optica presenting with life-threatening respiratory failure.
abstract: Dyspnea has rarely been reported as a presenting symptom in patients with neuromyelitis optica (NMO). We report an unusual case of NMO relapse presenting with rapidly progressive respiratory failure and briefly discuss the possible pathophysiological mechanisms of this potential life-threatening complication of NMO.
  
  
  
  The 58-year-old woman with a history of bilateral optic neuritis presented to the emergency department with rapidly worsening dyspnea. Cervical spine magnetic resonance imaging showed extensive abnormal signal with involvement of the medulla oblongata. Since in our patient chest radiography failed to disclose a diaphragmatic palsy that is commonly observed in patients with phrenic nerve involvement, this acute manifestation of the disease may be attributed to brainstem involvement instead of cervical myelitis.
  
  
  
  Clinicians should be aware of this atypical presentation of NMO, which needs to be promptly recognized and aggressively treated.
authors.affiliation: a Department of Neurology, Christian Doppler Klinik , Paracelsus Medical University , Salzburg , Austria.|b Department of Neurology , Franz Tappeiner Hospital , Merano , Italy.|f Spinal Cord Injury and Tissue Regeneration Center , Paracelsus Medical University , Salzburg , Austria.
authors.forename: Raffaele
authors.initials: R
authors.lastname: Nardone
authors.affiliation: c Children's Hospital of Pittsburgh at the University of Pittsburgh Medical Center , Pennsylvania , USA.
authors.forename: Giulio
authors.initials: G
authors.lastname: Zuccoli
authors.affiliation: b Department of Neurology , Franz Tappeiner Hospital , Merano , Italy.|d Department of Neurological and Movement Sciences , University of Verona , Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Brigo
authors.affiliation: a Department of Neurology, Christian Doppler Klinik , Paracelsus Medical University , Salzburg , Austria.|f Spinal Cord Injury and Tissue Regeneration Center , Paracelsus Medical University , Salzburg , Austria.
authors.forename: Eugen
authors.initials: E
authors.lastname: Trinka
authors.affiliation: e University of Arkansas for Medical Sciences , Little Rock , USA.
authors.forename: Ryan T
authors.initials: RT
authors.lastname: Fitzgerald
mesh_terms: D001933:Brain Stem / Q000000981:diagnostic imaging / Q000473:pathology; D005260:Female; D006801:Humans; D008875:Middle Aged; D009471:Neuromyelitis Optica / Q000097:blood / Q000150:complications / Q000175:diagnosis*; D012131:Respiratory Insufficiency / Q000175:diagnosis* / Q000209:etiology; D012698:Serologic Tests; D013116:Spinal Cord / Q000000981:diagnostic imaging / Q000473:pathology
keywords: Anti-aquaporin-4 antibodies; Brainstem; Cervical spine; Neuromyelitis optica; Respiratory failure