Case Presentation
A 26-year-old woman was presented with apathy, affective incontinence and motoric aphasia.
Medical History
- The patient had a 9-year history of relapsing remitting multiple sclerosis
- The patient was treated with interferon beta 1a and dimethylfumarate under which she had developed several relapses, therefore, switched to fingolimod.
- Six, weeks ago, fingolimod was discontinued due to persisting disease activity in the form of optic neuritis and lymphopenia of 225/μl.
Clinical Exam
Her MRI revealed:
- Numerous tumefactive lesions with gadolinium enhancement
- Edema atypical of her prior disease course
Her neurological evaluation showed:
- Inability to eat or drink
- Psychomotor agitation
- Inability to communicate with caregivers
- Expanded Disability Status Scale (EDSS) of 9.5
Laboratory findings:
- Peripheral blood lymphocyte count: 90/μl
- CSF analysis showed mild pleocytosis of 16/μl
- 3 independent PCRs for JCV-DNA from serum and CSF were negative
- An extensive PCR and serological workup for borrelia, lues and cryptococcosis was negative
- Anti-Aquaporin-4- and anti-MOG-antibodies were absent
- MR spectroscopy of a progressive lesion in the left frontal lobe showed creatinin, cholin and N-acetylaspartate slightly decreased & lactate slightly increased
Diagnosis
The patient was diagnosed with acute multiple sclerosis lesion.
Preliminary Treatment
- The patient was initiated on methylprednisolone therapy (1 g/d) over 5 days.
- Her neurological status deteriorated further.
- She was started on plasmapheresis and began to slowly improve.
Post-Treatment Outcomes
After 4th plasmapheresis,
- The patient was able to communicate and walk.
- She was able to ingest small amounts of food.
- MRI showed a decrease in the size and number of lesions, along with the gadolinium enhancement.
After 7th plasmapheresis,
- She was transferred to a rehabilitation facility with an EDSS of 7.5.
After 2 weeks,
- She developed right sided hemiparesis.
- The patient was started on corticosteroid therapy & readmitted.
- Her peripheral lymphocytes were raised to 890/μl but within the normal range.
- MRI revealed an overall decrease of gadolinium-enhancing lesions one subcortical lesion had remained active.
Further Treatment
- With no improvement, corticosteroids were discontinued.
- A 2nd cycle of seven plasmaphereses was started
- The patient improved daily and was released to a rehabilitation facility again.
Follow-up
After 7 weeks,
- 1st dose of ocrelizumab 300 mg was administered.
6 months later,
- The patient remained relapse-free.
- She showed clinical improvement with ability to walk independently up to 1 km without help (EDSS 4.5).
- MRI found a further remission with no remaining gadolinium enhancement.