The general examination, although usually unremarkable, may reveal signs suggestive of an underlying systemic infection or autoimmune disorder. Abdominal examination may reveal a distended bladder. On the neurological examination, the presence of any mental status changes suggests that the myelitis is a component of a more diffuse process, such as acute disseminated encephalomyelitis (ADEM). In the acute stages, muscle tone is flaccid in affected limbs. All sensory modalities should be carefully assessed. A spinal cord sensory level is usually located in the thoracic region (80%) and less commonly in the cervical (10%) or lumbar (10%) area.5 In the acute phase, deep tendon reflexes are depressed in approximately 70% of patients and later become hyperactive. Similarly, Babinski responses may be negative early in the acute phase, but soon become positive, indicating upper motor neuron dysfunction.