Snake-eyes appearance on spinal cord MRI due to acute anterior poliomyelitis in a child in Togo: a case report

Abstract Introduction The “snake-eyes” appearance (SEA) refers to a unique radiological finding that appears as bilateral hyperintense symmetric, circular or ovoid foci on T2-weighted axial magnetic resonance imaging (MRI) sequences in the anterior horn cells of the spinal cord. This condition is rarely reported in association with infections, such as acute anterior poliomyelitis (AAP). In sub-Saharan Africa, AAP is a major cause of acute flaccid paralysis (AFP) in children; however, the associated MRI abnormalities have rarely been reported. Here, we report a case of SEA caused by AAP in a 3-year-old child in Togo, West Africa. Case presentation In January 2020, a 3-year-old boy with sickle cell trait, who was not vaccinated against poliomyelitis, was admitted for tetraplegia without sphincter disorders. Ten days before admission, onset progressed rapidly within 48 h. Paralysis was preceded by fever and vomiting three days earlier. The infection was treated as malaria attack. Examination revealed irritability, fever of 38 °C, and flaccid tetraplegia. MRI revealed “snake eyes” on axial imaging. A bolus of injectable methylprednisolone was administered and motor physiotherapy initiated. A stool sample sent approximately 2 weeks later revealed the presence of circulating vaccine-derived poliovirus type 2 (cVDPV2). Six months later, the patient continued to show flaccid tetraparesis with asymmetric bilateral amyotrophy. Conclusions Diagnosing polio is one strategy for the global eradication of poliomyelitis, which remains a worldwide concern. Poliomyelitis should be suspected in the presence of any AFP with a snake-eye appearance on a spinal cord MRI.