MS and Stroke?"MS and Stroke? Can they occur together.. case report (CPC)"
Case presentation slide summary Slide 1: 40 year old lady married + 4 children, born in Israel, with presumptive diagnosis of MS presenting with blurred vision of the right eye 2002 -Admitted with right leg weakness - Myelopathic signs on examination - MRI revealed inflammatory lesion T7-8 - LP: TP 501, no cells, OCB negative - Treated with steroids with marked improvement - No neurological symptoms until current presentation - At presentation mild sensory symptoms only AskTheNeurologist.Com Slide 2: Current admission 3 days prior to admission, after slight bump to head, noticed blurred vision of R eye Vision deteriorated over following 3 days with pain on eye movement AskTheNeurologist.Com Slide 3: Past history No other neurological problems No other clinical features referable to auto-immune disease ( e.g. SLE, Bechets) No history of miscarriage Serological abnormalities ( to be discussed) Had traveled to New England but no history of tick bite AskTheNeurologist.Com Slide 4: Examination General examination unremarkable RAPD on the right Fundoscopy normal Remainder of examination normal with no evidence of myelopathy Steroids started for presumptive MS exacerbation AskTheNeurologist.Com Slide 5: Laboratory investigation prior to admission Immunology ATG 87, 87 ( <100) 3.2003, 1.2004 ATPO 793, 538 ( <75)!! (TSH 3.56 - normal) ANA +2 / 4 (2002) ve x2 (2003,2004) ENA +ve x1 (2002) ve x2 ANCA ve x2 AskTheNeurologist.Com Slide 6: Laboratory investigation prior to admission Serology CMV past infection EBV past infection VZV past infection Toxoplasma neg Brucella neg VDRL neg Brucella neg Lyme +ve x2 ( 10.2003, 1.2004) AskTheNeurologist.Com MS and stroke Slide 7: Brain MRI AskTheNeurologist.Com Slide 8: Laboratory investigation during current admission FBC, Bioch normal ESR 18 LP: - Pressure 12 cm H2O - TP 488, no cells, OCB negative Anticardiolipin Abs negative pANCA cANCA negative ANA negative TSH normal Anti TPO 397 ( 0-35) Anti TG normal Homocysteine Pending AskTheNeurologist.Com Slide 9: Course Received high dose steroids Day 4: Ceftriaxone added, steroids tapered Day 5: improvement noted in vision Day 6 am : - mild left hemiparesis noted, steroid dose incresed Day 6 pm: witnessed tonic-clonic seizure. On examination, severe L hemiparesis Brain CT unremarkable AskTheNeurologist.Com Slide 10: Course cont. Further seizures: Unresponsive to benzodiazepines phenytoin, phenobarbital (RSE) Intubation, propofol IV MRI: Right MCA infarct Anticoagulant treatment commenced AskTheNeurologist.Com Slide 11: Brain MRI after Seizure AskTheNeurologist.Com Slide 12: Further Investigation Angiograpghy - decreased perfusion in R MCA territory TEE - no clot detected AskTheNeurologist.Com Slide 13: Course cont. Weaned from propofol and BZDs Extubated Marked improvement of hemiparesis AskTheNeurologist.Com Slide 19: Neurological features of chronic Lyme disease AskTheNeurologist.Com Slide 20: CSF in Chronic Lyme In early cases of neuroborreliosis, spinal fluid findings may still be negative. In cases of chronic disease, only mild elevations of protein may persist. In these circumstances, detection of B. burgdorferi DNA by PCR may be important to establish the diagnosis. AskTheNeurologist.Com Slide 22: Serology Both IgG and IgM responses can persist for over 10 years, even after successful antibiotic treatment False positive ELISA results can be caused by other bacteria (e.g. Treponema denticulata) or by a polyclonal B cell stimulation. Positive serology alone is not sufficient to make the diagnosis Cross-reactivities with syphilis tests do occur Direct detection methods (PCR) diagnostic AskTheNeurologist.Com Slide 23: Value of Serology AskTheNeurologist.Com Slide 27: Proposed diagnostic criteria c lo u d in g o f c o n s c io u s n e s s with re d u c e d wa ke fu ln e s s , a tte n tio n , o r c o g nitive fu n c tio n n o C S F e vid e n c e o f b a c te ria l o r vira l infe c tio n h ig h s e ru m c o n c e n tra tio n (o r tite r) o f a ntith yro id m ic ro s o m a l, a n tith yro id p e ro xid a s e , o r a ntith yro g lob u lin a n tib o d ie s AskTheNeurologist.Com Slide 28: Thyroid function AskTheNeurologist.Com Slide 29: AskTheNeurologist.Com Slide 30: AskTheNeurologist.Com Slide 31: MRI in Hashimoto Encephalopathy AskTheNeurologist.Com Slide 35: Antiphospholipid syndrome as a cause of MS and stroke? Can simulate MS especially in patients with myelitis and optic neuritis Especially in those without OCBs ( Karussis et al, Annals of Neurology 1998 ) Associated with stroke in the young However: Anticardiolpin negative during current hospitalisation (steroids should not cause disappearance) Lupus anticoagulant not checked prior to heparin AskTheNeurologist.Com Slide 36: MS Clinical and MRI features fit both MS and stroke Against OCB ve twice Stroke ( therefore other conditions must be excluded) AskTheNeurologist.Com Slide 41: Normal values: TPO-Ab 010 IU/mL; Out of 31 MS patients 5 (16%) had Anti TPO Abs AskTheNeurologist.Com Slide 44: CNS Vasculitis - GANS - PAN ( but no systemic features) GANS For Against Can simulate relapsing Optic nerve and spinal cord remitting course of MS involvement rare Stroke Clinical course typical of MS No headache MRI probably too severe given mild clinical features prior to stroke CSF and angiography normal AskTheNeurologist.Com Slide 45: Is MS associated with alteration of platelet function? platelet aggregation and MS Neu et al 1982 Acta neurologica Scand. AskTheNeurologist.Com Slide 46: Measured in vitro platelet aggregation in 30 definite MS patients and compared to 15 healthy subjects Both spontaneous and agonist-induced aggregation was measured 80 70 60 Agg % 50 40 MS 30 CONTROL 20 10 P < 0.01 0 ADP 5-HT AskTheNeurologist.Com Slide 47: Summary 1. MS and stroke is diagnosis of exclusion 2. Lyme disease unlikely but should be excluded via PCR because of the stroke 3. Hashimoto Encephalopathy attractive diagnosis however no encephalopathy clinically or electrophysiologically. 4. APLAS clinically fits..but no lab evidence ( Lupus Anticoagulant not checked) 5. Granulomatous angiitis unlikely but cannot be ruled- out 100% without brain biopsy 6. HIV should be tested for completeness AskTheNeurologist.Com You can go to our forum to ask one of our experts in MS and stroke a question. 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