Early rituximab and structured rehabilitation drive rapid functional restoration in steroid- and PLEX-refractory NMOSD: a case report.

INTRODUCTION AND

IMPORTANCE

Neuromyelitis optica spectrum disorder (NMOSD) is an antibody-mediated central nervous system disorder, typically presenting with optic neuritis (ON) and longitudinally extensive transverse myelitis (LETM). Detection of anti-aquaporin 4 (AQP4) antibodies establishes the diagnosis, even in patients without classic clinical features.

CASE PRESENTATION: A 32-year-old female presented with progressive ascending quadriparesis and sensory deficits. Neurological examination revealed significant hypotonia and weakness, more pronounced in the lower limbs. Spinal magnetic resonance imaging showed LETM involving cervical and thoracic segments, correlating with symptoms. AQP4-IgG positivity confirmed the diagnosis of NMOSD. The patient showed no improvement with intravenous methylprednisolone and plasmapheresis. Subsequent early initiation of Rituximab, combined with comprehensive physiotherapy, resulted in significant functional recovery within a follow-up period of 1 year.

CLINICAL DISCUSSION: NMOSD variably presents with limited or atypical presentations. Early-stage disease may be easily overlooked, particularly in the absence of classical optical or spinal symptoms. Early recognition followed by timely initiation of pharmacotherapy and prompt escalation to targeted immunotherapy like Rituximab - which depletes peripheral B cells and reduces pathogenic AQP4-IgG antibody production targeting disease pathophysiology - can lead to significant neurological improvement. When combined with comprehensive physiotherapy, these interventions support motor recovery, enhance mobility, and improve overall quality of life.

CONCLUSION

Early recognition of NMOSD and timely escalation to Rituximab, especially when first-line therapies fail, can drive meaningful neurological recovery. Coordinated physiotherapy further strengthens functional outcomes, highlighting the importance of an integrated therapeutic approach in severe or refractory disease.