Multiple Sclerosis and other Neurological Conditions
Margaret Sweeney, DO
Resident Physician PGY-2
Memorial Healthcare System
Miami, Florida, United States
Cody Barbari, DO
PGY-4, Chief Resident
Memorial Healthcare
Hollywood, Florida, United States
Joanne Delgado Lebron, MD
Attending Physician
Memorial Healthcare System
Hollywood, Florida, United States
Margaret Sweeney, DO
Memorial Healthcare System
Miami, Florida, United States
Tumefactive Multiple Sclerosis
Case Description:
65-year-old male presented to the ED with left vision loss. MRI Brain/Orbits revealed enhancing lesions including anterior segment of the left optic nerve. Patient was admitted with concern of optic neuritis in the setting of demyelinating disease. He received six doses of IV steroids and was discharged on a Medrol Dosepak. The patient represented to the ED five days later complaining of unsteady gait and falls. Repeat MRI Brain demonstrated several partially enhancing lesions concerning for active demyelinating plaques. Lab work revealed negative findings. He was further treated with six additional doses of IV steroids and transferred to inpatient rehabilitation facility (IRF). Initially, patient was noted to have bilateral lower extremity (BLE) weakness, left worse than right. During his IRF course, he became flaccid in BLE with complete paralysis. MRI Thoracic Spine showed restricted diffusion at T6-T8. Neurology recommended plasma exchange and rituximab infusion. Patient had continued flaccidity after treatment.
Discussions:
Tumefactive Multiple Sclerosis (MS) is a rare MS variant. Pathophysiology is T-cell and B-cell response leading to oligodendrocyte injury, which can impair myelin production and maintenance. Brain imaging in Tumefactive MS will demonstrate demyelinating lesions which mimic tumors or other lesions. Diagnosis is made clinically, with cerebrospinal fluid showing oligoclonal bands, and imaging revealing characteristic lesions. Its course is usually relapsing and remitting. First-line treatment during acute relapses includes IV steroids, then plasma exchange, and lastly rituximab for refractory cases.
Conclusions:
Tumefactive MS is a variant of MS which can produce large demyelinating lesions on brain imaging. Since it is a very rare variant of MS diagnosis can be challenging, leading to a delay in treatment and interruptions in rehabilitation plan due to relapses. Awareness of this variant as well as quick management during relapses are important to prevent rapidly developing impairments and disability.
