Acute paraplegia in patient with spinal dural arteriovenous fistula after lumbar puncture and steroid administration: A case report

•Spinal dural arteriovenous fistula is an uncommon cause of longitudinal transverse myelitis.•Spinal dural arteriovenous fistula can be easily misdiagnosed.•It usually presents with venous congestive myelopathy symptoms and misdiagnosis is common.•Prescence of flow voids on MRI should raise the suspicion of underlying fistula.•Intravenous steroid and lumbar puncture may be associated with acute neurological deterioration. Spinal dural arteriovenous fistula (SDAVF) is an uncommon cause of longitudinal extensive transverse myelitis (LETM). It usually presents with vague congestive myelopathy symptoms and diagnosis is usually difficult on initial presentation. Common daily neurological interventions can aggravate the underlying pathophysiology leading to undesirable acute neurological deterioration. Intravenous steroids administration and lumbar (LP) puncture as a diagnostic tool are amongst the most commonly reported aggravating interventions. This rare case presentation highlights this association with its negative impact on the patient outcome in misdiagnosed cases. The authors present a sixty-eight-year-old male with paraplegia following steroid administration and LP for presumed inflammatory/autoimmune LETM in the setting of misdiagnosed SDAVF. The absence of flow voids on the conventional T2-weighted magnetic resonance image (MRI) lead to misdiagnosis. He had satisfactory neurological recovery few hours after surgical disconnection. SDAVF is known to cause congestive myelopathy symptoms. Spinal angiogram is the gold standard for diagnosis. Although the exact mechanism is not fully understood, misdiagnosed cases like our case can develop severe neurological deterioration with steroid administration and lumbar puncture. Although SDAVF is an uncommon cause of LETM, Clinicians should carefully exclude it before proceeding to steroid administration or performing LP as they can lead to devastating neurological deterioration.