Table of Contents
Washington University Experience | MYELIN (IMMUNE-MEDIATED) | Balo Concentric Sclerosis | 2A0 Case 2 History
Case 2 History ---- This is a 27-year-old woman without past medical history who 2 weeks prior to presentation developed fatigue, impaired fine finger movements and slurred speech followed by progressive neurological decline in an OSH including somnolence, dysarthric, left-sided weakness involving the face, arm, and neck within one week. Brain MRI encountered multiple lesions with a T2 hyperintensity and post-contrast enhancement with suspicion of demyelinating process including tumefactive MS versus ADEM. The patient received high dose iv steroids for 5 days, however, the patient had no improvement. She subsequently was treated with plasmapheresis x2. Shortly after her plasmapheresis she developed hemodynamic deterioration with hypotension and hypoxia and was transferred to our hospital. Plasmapheresis and oral prednisone were begun again. Repeat MRI showed bilateral multifocal T2 hyperintense lesions with decreased enhancement on contrast in comparison to her initial MRI. Neuroimmunology thought that her MRI findings were very atypical of demyelinating disease, specifically Balo due to the fact that the lesion was less concentric, more cystic and more multifocal than expected, and that ADEM was less likely on the differential because of her absence of an encephalopathic picture and lack of preceding illness/vaccination. CSF workup was positive for 12 oligoclonal bands; 7 WBC, 0 RBC, 52 glucose, protein 35. She was negative for EBV, VDRL, RPR, HIV, JC, Lyme, Toxo, ANA, ENA, neurocysticercosis. ESR 29 CRP 0.4, ACE 1149. The patient's left sided motor strength improved in both arm and leg with decreased hyperreflexia). An ophthalmology exam showed no signs of an acute inflammatory process/optic neuropathy. MRA/MRV showed no signs of vasculitis. Repeat MRI showed, however, progressive worsening, and a brain biopsy was performed.
