CASE PRESENTATION A nine-month-old girl from northern Manitoba presented in September 2014, with a three-day history of vesicular rash on the soles of her feet. She was diagnosed with hand, foot and mouth disease, and discharged from the local nursing station. Over the next 24 h, she developed cough and fever that led to progressive vomiting, diarrhea and increased work of breathing, causing significant oxygen requirements, which led her to be transferred to a tertiary care centre. On admission, she required intubation and fluid resuscitation for respiratory failure and hypotension. On physical examination, she was afebrile. On respiratory examination, there were diffuse crackles and coarse breath sounds bilaterally. Cardiac and abdominal examinations were normal. The only remaining rash consisted of vesicular lesions on an erythematous base on the sole of the right foot. Laboratory tests revealed a white blood cell count of 4.3×109/L, including an absolute neutrophil count of 1.7×109/L. The rest of the complete blood cell count, liver enzyme levels, renal function and electrolytes were normal. Blood and endotracheal tube aspirate cultures, obtained before vancomycin and ceftriaxone were administered, were negative. Urine analysis revealed no leukocytes or nitrites; however, urine culture was positive for pansusceptible Escherichia coli (2×106 CFU/L). Cerebrospinal fluid obtained one day after admission, when her hemodynamic status improved, revealed a total white blood cell count of 28×106 cells/L, including 66% lymphocytes, 8% neutrophils, 26% monocytes, glucose 5 mmol/L, protein 0.21 g/L and a few red blood cells observed on microscopy. Bacterial cultures and polymerase chain reaction (PCR) for enterovirus and herpes simplex virus were negative. Stool sent for electron microscopy was negative, but stool for viral culture was pending. Chest x-ray revealed a right middlelobe infiltration. A nasopharyngeal aspirate and bronchoalveolar lavage sent for respiratory virus panel PCR, which included adenovirus, human coronavirus OC43, 229E and NL63, repiratory syncytial virus A and B, influenza A and B, parainfluenza 1, 2, 3 and 4, enterovirus, rhinovirus A, B and C, bocavirus 1 and 2, and human metapneumovirus, were both negative. Acid-fast bacilli smear and culture, bacterial culture and fungal culture from the bronchoalveolar lavage were negative. The patient became unable to move her upper extremities on day 2 of admission. Magnetic resonance imaging of the head and spine was performed on the same day, and revealed restricted diffusion at the dorsal brain stem and patchy areas of prolonged signal intensity involving the cranial-cervical junction, cervical and, to a lesser extent, the thoracic and lumbar spinal cord, suggestive of transverse myelitis with rhomboencephalitis. An autoimmune-mediated process was suspected due to the absence of detection of infectious agents. A three-day course of pulse methylprednisolone led to no improvement. The patient developed increased ventilator requirements, including high frequency jet ventilation on days 6 to 11 of admission. The patient slowly recovered with supportive care over the next five days. She was extubated on day 14 of admission and discharged on day 37, with residual impaired mobility of her right arm. She was seen two months after discharge with improved, but ongoing, difficulty lifting her right arm to her face, and was unable to lift her right arm above her shoulder. She is followed by physiotherapy, occupational therapy and pediatric neurology.