Reversible hypertensive myelopathy in a patient with IgA nephropathy

Case presentation: A 37-year-old woman, 5 months after the diagnosis of IgA nephropathy (IgAN), presented severe nuchal pain, right inferior limb weakness, and bilateral low visual acuity in the context of acute renal failure (ARF). Examination showed visual acuity 20/200 in the right eye (RE), 20/40 in the left eye (LE), papillary and macular edema in RE. MRI showed infratentorial hyperintense lesions and extensive myelitis from C1-C7. The patient had complete resolution of symptoms after pulse therapy with methylprednisolone, followed by 6 monthly doses of cyclophosphamide due to marked worsening of glomerular sclerosis. Autoantibody tests were negative, including anti-AQP4, but anti-MOG was not performed. CSF analysis showed no alterations, with absence of OCBs. OCT showed hard exudate and reduced RNFL in the RE. The patient had recurrences with low visual acuity in the RE and right hemiparesis associated with ARF, with complete improvement. New MRIs showed the disappearance of the lesions observed in the previous exams. However there was a hyperintensity observed in the right optic nerve, hemosiderin deposits due to microhemorrhages in the nucleocapsular regions, and new extensive centromedullary hyperintensityl in the thoracic spinal cord from T6 to the medullary cone. Discussion: Cases of reversible hypertensive myelopathy (RHM) have been described in patients with hypertensive emergencies. MHR - spinal cord involvement similar to posterior reversible encephalopathy syndrome (PRES) - is a rare presentation, marked by the disappearance of spinal cord injuries. The neuroretinitis presented is also a vascular complication described in the literature. Ruling out demyelinating pathologies such as neuromyelitis optica and MOGAD is necessary for diagnosis. Final comments: This case suggests that reversible myelopathy and neuroretinitis can be a manifestation in patients with IgAN. Physicians must be careful not to confuse such acute symptoms with demyelinating diseases.