Tumefactive multiple sclerosis

Abstract

A 44 year old man presented with a 2-month history of progressive right upper extremity weakness, confusion and visual change. Physical exam revealed weakness, hyperreflexia on the right side and right homonymous hemianopia. MRI of the brain showed multiple ring-enhancing lesions located in both cerebral hemispheres. CSF analysis disclosed elevated protein with positive oligoclonal bands and myelin basic protein. Stains and cultures for bacteria and mycobacteria were negative. Serologies including HIV, Toxoplasmosis, and Lyme were all negative. Patient was treated with high-dose IV corticosteroid and clinically improved. One month later, he presented with increasing confusion, aphasia and progressive weakness. Repeat MRI of the brain revealed worsening multiple ring-enhancing lesions with surrounding vasogenic edema in most lesions. High-dose corticosteroid was promptly started. There was also concern about infection, especially brain abscess; hence, intravenous ceftriaxone, vancomycin, and metronidazole were empirically given. Due to uncertainty of diagnosis, first brain biopsy at right frontal lobe lesion yielded non-specific gliosis. Repeat MRI brain showed increasing number of ring-enhancing lesions in both cerebral hemispheres. As a result, a second brain biopsy was performed, which showed an active demyelinating process consistent with multiple sclerosis. Patient experienced severe disability and was discharged to long-term facility with slowly tapered schedule of corticosteroid. He was readmitted several times and eventually family decided hospice care.