Catastrophic Neurological Collapse Following Push-Up Exercise: A Rare Case of Spontaneous Hematomyelia Causing Acute Paraplegia in a Healthy Young Adult.

Spontaneous hematomyelia, or non-traumatic intramedullary spinal cord hemorrhage, is a rare and potentially devastating neurological condition. Unlike hematomyelia resulting from overt trauma, spontaneous cases occur in the absence of significant injury and present substantial diagnostic and therapeutic challenges. Etiologies are diverse and include spinal cord neoplasms, coagulopathies, anticoagulant use, spinal arteriovenous malformations (AVMs), radiation-induced vasculopathy, minor mechanical insults, and systemic inflammatory conditions such as COVID-19. Given its rarity and the high risk of permanent neurological impairment, timely recognition is essential. We report the case of a previously healthy 19-year-old male who developed sudden-onset lower limb weakness and back pain following a session of push-up exercises. Within 3 h, he progressed to complete paraplegia. Initial treatment at a local primary hospital was unsuccessful, and he was referred to Hawassa University Comprehensive Specialized Hospital on the fourth day of illness. Magnetic resonance imaging (MRI) of the spine revealed an intramedullary spinal cord hemorrhage consistent with spontaneous hematomyelia. Based on imaging features and clinical context, a presumptive diagnosis of juvenile spinal AVM was made; however, digital subtraction angiography (DSA) was not feasible due to financial and infrastructural constraints. The patient received conservative management, including supportive care and physiotherapy. Unfortunately, no neurological recovery was observed at nine-month follow-up. This case underscores the need to consider spontaneous hematomyelia in the differential diagnosis of acute flaccid paraplegia, especially in young, previously healthy individuals without trauma or anticoagulant exposure. It also raises awareness of physical exertion, such as upper-body resistance exercise, as a potential trigger for spinal AVM rupture. Moreover, the case highlights the significant impact of limited diagnostic and therapeutic resources in low-income settings, which may hinder timely intervention and worsen neurological outcomes.