Child Neurology: Tick paralysis A diagnosis not to miss

A 4-year-old girl presented to our tertiary care hospital with a complaint of lower extremity weakness and unsteady gait for 2 days. She was able to pull herself to stand but could not stand unsupported. She had no sensory symptoms or pain. She did not complain of any weakness in her arms, trunk, face, or neck. She had no bowel or bladder incontinence or reten-tion. On presentation to the emergency department, she had minimal antigravity strength of the lower extremities but normal strength elsewhere. In addition, she was areflexic in both lower extremities and had a wide-based, unsteady gait but no appendicular dysmet-ria or titubation. Sensory examination was normal. After consultation by the neurology service, MRI of the brain and total spine were completed and a plan was made for subsequent lumbar puncture. Lyme disease antibodies were drawn because of exposure to a wooded area in West Virginia; these were negative. MRI of the spine showed syringomyelia extending from T5 to T8 and an extramedullary, intradural cystic lesion dorsal to the spinal cord from T1 to T4, which was believed to be consistent with an arachnoid cyst. finding, the neurosurgical service was consulted, who believed that this cyst and the associated syrinx were the source of her paralysis. The following day, she was taken to the operating room for fenestration. Subsequent to the fenestration, repeat imaging showed resolution of syringomyelia.