# Neurological Mystery Post Travel: An Atypical Presentation and Partial Recovery With Immunotherapy

## TL;DR

A woman with unusual neurological symptoms after travel showed partial recovery with immunotherapy, highlighting the role of immune treatments in undiagnosed cases.

## Contribution

This case emphasizes the use of empirical immunotherapy in atypical neurological presentations with uncertain diagnoses.

## Key findings

- Empirical IVIG therapy led to clinical improvement despite lack of definitive diagnosis.
- The patient's vitiligo flare-up suggested heightened autoimmune activity around symptom onset.
- South Indian ethnicity may influence autoimmune and neurological disorder presentations.

## Abstract

This case highlights the diagnostic challenges in atypical neurological presentations and the role of empirical immunotherapy despite the absence of a definitive diagnosis. We present a South Indian woman in her 40s who developed progressive lower limb weakness and respiratory compromise after recent international travel. Initially suspected to have Guillain-Barré syndrome (GBS), extensive investigations, including electromyography (EMG), nerve conduction studies (NCS), and cerebrospinal fluid (CSF) analysis, failed to confirm a clear diagnosis.

Despite this uncertainty, empirical intravenous immunoglobulin (IVIG) therapy resulted in clinical improvement, supporting the likelihood of an immune-mediated process. Notably, the patient had been experiencing an ongoing flare-up of vitiligo, an autoimmune disease characterized by immune-mediated destruction of melanocytes, for approximately six months leading up to and during the onset of neurological symptoms, suggesting heightened autoimmune activity around the period of symptom onset. Additionally, the patient's South Indian ethnicity is relevant, as autoimmune disorders, including neurological conditions, may have distinct presentations and prevalence among South Asian populations due to genetic and environmental factors.

The patient’s prolonged ICU stay, need for mechanical ventilation, and complications such as stridor and vocal cord dysfunction underscore the complexity of managing undifferentiated neurological cases.

This case serves as an important educational tool, demonstrating the limitations of standard diagnostic criteria in rare or evolving neurological syndromes, the importance of empirical immunotherapy in suspected immune-mediated conditions, and the need for a multidisciplinary approach with careful follow-up. By highlighting the intersection between neurology, immunology, and critical care, this case reinforces the importance of clinical judgment and individualized treatment strategies when conventional diagnostics fall short.