In January, 2016, a 15-year-old girl with a history only of an ovarian cyst was admitted to hospital in Pointe-à-Pitre, Guadeloupe, with left hemiparesis. 7 days previously she had presented to the emergency department with left arm pain, frontal headaches, and conjunctival hyperaemia, but no fever, signs of meningeal irritation, or sensory or motor defi cits. The day of admission, she developed acute lower back pain, paraesthesia on the left side of her body, and weakness in her left arm. On admission she had slight left-sided weakness and proximal pain of the left arm and leg, exacerbated on movement, but no fever or signs of meningism, and Glasgow Coma Score (GCS) 15. Laboratory analyses were normal except for raised leucocytes (11·5 × 10⁹/L) and polymorphonuclear leucocytes (9·2 × 10⁹/L). Brain MRI was normal.On day 2, she developed dysuria and urinary retention needing catheterisation, but no abnormal urinary frequency or urgency. The left-sided hemiparesis and pain worsened, and we noted loss of temperature sensation below the T2 dermatome on the left and T4 on the right, and bilateral Hoff man signs. Spinal MRI showed lesions of the cervical and thoracic spinal cord. The cervical lesion was enlarged, suggesting oedema (fi gure). Conus medullaris and lumbar roots were normal, suggesting the bladder dysfunction could be linked to spinal damage. Electromyography and cerebrospinal fl uid examination (including isoelectric focusing protein profi le) were normal. We detected high concentrations of Zika virus on specifi c real-time reverse PCR (Eurobio, Les Ulis, France) in serum, urine, and cerebrospinal fl uid on the second day of her admission (9 days after symptom onset). PCR for varicella zoster and herpes simplex viruses, Legionella, and Mycoplasma pneumoniae in her cerebrospinal fl uid were negative. She had no serological signs of acute infection with cyto-