Paroxysmal Symptoms in Multiple Sclerosis- Interesting of Case Series

سال انتشار: 1398
نوع سند: مقاله کنفرانسی
زبان: انگلیسی
مشاهده: 552

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شناسه ملی سند علمی:

MSC16_073

تاریخ نمایه سازی: 11 آذر 1398

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Introduction: Paroxysmal symptoms are demyelinating events produced sudden onset, transient, recurrent symptoms that mistook them with several neurologic disorder like transient ischemic attacks, epilepsy and etc. Paroxysmal symptoms in multiple sclerosis (MS) can as the first clinical manifestation or occur in the course of disease and occur in 8.6% of patients with multiple sclerosis at some point of course of disease. Paroxysmal symptoms are characterized by their brevity, frequency, stereotyped fashion and respond to carbamazepine, if untreated they tend to continue in cluster for days up to a few months. Paroxysmal symptom in MS included:- Paroxysmal dystonia - Painful tonic spasm (seizure)- Paroxysmal dysarthria, ataxia, diplopia, vertigo- Hemi facial spasm - Trigeminal neuralgia - Paroxysmal itching - Paroxysmal dysesthesia or paresthesia Paroxysmal symptoms in multiple sclerosis masquerading as transient ischemic attacks (TIAs)Case I: A 45- year old man was presented with 4 weeks of episodes, transient, sudden- onset blurred vision and a heaviness in his arm. He experienced 10-20 stereotyped episodes daily, each lasting 5-10 seconds, passing spontaneously or when he made neck movements. Between attack patient was well, with careful further questioning he recalled an episode of right- leg numbness one year previously that lasted 2 weeks. He had no history of neurological symptoms and no medical history. The cardiovascular and neurological examination were normal routine blood test, a 24-h electrocardiogram and EEG were normal. T2 FLAIR brain MRI showing lesions in the corpus callosum, that consistent with demyelination, with single daily dose of 100 mg of carbamazepine, symptoms were resolve.Case II: A 32- year- old male developed episodic, transient sudden- onset dizziness, left face numbness, and right limb weakness attacks repeat 20-30 times a day with, each period lasting 10-20S. He was well between the attacks, he had no cardiovascular risk factors and no history of migraine and his neurologic exam was normal. Echo cardiography, transcranial Doppler (TCD). The serum autoantibody and connective tissue test were negative. In gadolinium MRI-FLAIR several hyper intense enhancing lesions in midbrain and periventricular region had been found, CSF exam reveals oligoclonal bands (OCBs) with IV methylprednisolone 1000 mg for 5 days and carbamazepine 200 mg daily his attacks resolved completely 3 weeks later. Paroxysmal acute tonic spasms and hemi dystonia as the first manifestation of multiple sclerosisTonic spasms: Dramatic spasms of a limb or entire body, after tremor is the second most common movement disorder in MS, is stereotyped, painful attacks of unilateral dystonic posturing of the limbs. They are occasionally bilateral attacks last between 30 seconds and 2 minutes and can occur up to 60 times a day. Occur in patients with large demyelinative lesions of cervical spine. Case II: A 36 years- old women presented with RT- upper limb dystonic posture abnormal posture was paroxysmal, intermittent and painful, in brain MRI in FLAIR sequence was hyper intense focal lesion in left striatum and in cervical MRI there was hyper intense lesion in C6 on T2 weighted images. Cardiologic evaluation and vacuities profile were normal with methylprednisolone pulse therapy, hemi dystonia was releave. Hemi facial spams in multiple sclerosis: Multiple sclerosis may presenting with hemifacial spasm and can be a sign of relapse in patients with established multiple sclerosis brief repetitive, stereotyped attacks, last few seconds to few minutes and may occur to 200 times per day.Case IV: A 33 year- old male presents with episodes of twitching of his left eye and left cheek, beside brief episodes of left hemifacial spasm neurologic exam was normal in brain MRI in FLAIR sequences there is ipsilateral pontine lesion and in left anterior hemisphere. Painful Paroxysmal tonic seizure (PTS) due to multiple sclerosisCase V: Hiroshi shibaakin reports PTS in 11 Japanese patients with MS. The occurrence and trigger zone of the PTS were closely correlated with sensory impairment of cord origin, including Lhermitte sign. MRI shows extensive demyelinating lesions in the spinal cord. Carbamazepine suppresses the PTS. Tonic spasms are a common clinical manifestation in patients with neuromyelitis optica.Trigeminal neuralgia due to multiple sclerosis: Is the most common paroxysmal disturbance. The clinical syndrome is usually indistinguishable from that in Non-MS Patients, except that onset tends to occur at an earlier age and symptoms are more frequently bilateral.Case VI: A 55- year- old man presented with 16- year history of relapsing/ remitting multiple sclerosis, for 1 year patient had been complaining of electric shock- like, that last a second to a few minutes and involved the first and second trigeminal divisions of both sides simultaneously. Brain MRI revealed pontin demyelinating plaque. Simultaneous bilateral trigeminal neuralgia should consider diagnosis of multiple sclerosis.Paroxysmal itching in multiple sclerosis: Paroxysmal itching in MS is rare, but may be the first and only symptom at the onset of MS.Case VII: A 27 years old women has frequent attacks, of itching affecting, initially the lateral side of the right lower leg for two months, these were of sudden onset, lasted only a few minutes and cease rapidly. The attacks occurred at least five times a day and were not relived by scratching, dermatologist did not find signs of abnormality.In last one year ago she noted weakness of her left leg for three months. There were numbness and hypoesthesia in both legs and weakness of right leg, brisk of deep tendon reflexes and extensive of both plantar responses. Brain MRI in FLAIR sequence shows hypersignal white matter lesions corresponding to demyelinating disease. Paroxysmal itching were resolve with high does methylprednisolone and carbamazepine. Benign paroxysmal positioning vertigo (BPPV) in Multiple sclerosis: Demyelinating lesions within the vestibular nuclei and in the root entry zone of cranial never VIII causes vertigo and in BPPV MS patients. Case VIII: A 43- year- old woman with rotatory positional vertigo and nausea visited, she had persistent upbeat nystagmus during the spine head roll test in the Dix- Hallpike test the left head- hanging position provoked torsional nystagmus toward the right for 45S. Neurologic examination was normal brain MRI in FLAIR sequence showed demyelinating lesions in brainstem and cerebellum. BPPV can results of vestibule- ocular reflex due to MS and although vertical nystagmus, accompanied by rotation, is also seen in patients with BPPV originated by the anterior semicircular canal.The rarity of this type of BPPV suggests that an imaging study is a prudent measure even when rotation is observed.Paroxysmal diplopia as the first manifestation of multiple sclerosisTransient diplopia may be early manifestation of multiple sclerosis.Case IX: A 30 year- old male presented with intermittent diplopia. In neurologic exam visual acuity and visual fields, and fundoscopic exams were normal. Ocular motility examination reveled impaired adduction and abduction in both eyes. With careful further questioning he recalled vertigo and paresthesia of the left arm in two years ago that after one weak without any investigation these symptoms were disappear contrast midbrain MRI were significant for multiple sclerosis, showing active lesion in the pons. Tests for autoimmune disease were negative.Conclusion: It is important to consider paroxysmal symptoms in differential diagnosis of MS. The most valuable tool in identifying paroxysmal symptoms is clinical history. Early diagnosis of MS and early initiation of the disease modifying therapy (DMT), leads to better prognosis.

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نویسندگان

a Chitsaz,

MD. Professor of Neurology, Isfahan University of Medical Sciences, Fellowship of Movement Disorder