Conclusions

This pediatric case of AQP4-IgG-positive NMOSD provides specific clinical lessons for managing severe demyelinating events temporally associated with COVID-19. First, it underscores that intractable vomiting must be recognized as APS, a critical sentinel presentation in atypical demographics such as pediatric males. Second, it highlights that a normal fundoscopy does not rule out optic neuritis; early MRI is essential to identify isolated retrobulbar enhancement and concurrent brainstem disease, aiding differentiation from MOGAD via anti-MOG testing. Finally, early CBA testing for AQP4-IgG proved crucial; given that AQP4-positive disease is associated with worse outcomes compared with MOGAD, aggressive therapeutic escalation (plasmapheresis and rituximab) in steroid-refractory cases was associated with neurological recovery.