Behavioral changes as the first symptom of multiple sclerosis: a case report

Acute pulmonary oedema and headache are both common. The former is usually cardiogenic in origin. Severe headache of sudden onset in a young person may be suggestive of subarachnoid headache. We describe a 24-year-old man who presented with headache and pulmonary oedema, finally ascribed to multiple sclerosis. This is the first report of neurogenic pulmonary oedema as the first symptom of multiple sclerosis. We review the neuroanatomical basis and experimental evidence for neurogenic pulmonary oedema.

Vestibular evoked myogenic potentials and MRI in early multiple sclerosis: Validation of the VEMP score

A 39-year-old woman was admitted to hospital because of a sensory hemisyndrome caused by a contrast-enhancing demyelinating lesion of the cervical cord. MRI, CSF examination and subsequent clinical and neuroradiological follow-up led to the diagnosis of multiple sclerosis. The patient had noticed an involuntary contraction of a small muscle fascicle on the right side of the chin for a year. Electromyographic and video recordings confirmed the synkinesis between the orbicularis oculi and lower facial muscles, a finding distinct from the myokymic discharges reported in multiple sclerosis and more similar to the synkinesis associated with hemifacial spasm.

Serum markers of multiple sclerosis - a new approach

McAlpine's Multiple Sclerosis

Behavioural, hyperthermic and neurotoxic effects of 3,4-methylenedioxymethamphetamine analogues in the wistar rat

Sirs: Acute transverse myelitis is a spinal cord inflammatory process of unknown aetiology. Involvement of an autoimmune response is the most widely accepted mechanism [1, 2, 3]. Some cases have been reported concomitantly or after a viral infection [4]. In some patients it can be the first symptom of multiple sclerosis [5]. The severity of the neurological symptoms and sequelae depend on the location of the lesion and on the severity of the underlying lesions, oedema, demyelination and/or axonal lesions. The spinal cord clinical syndrome includes autonomous, motor and sensory disorders either in isolation or in combination. The experience of illusory symptoms or phantom limb movement during transverse myelitis or as a symptom of multiple sclerosis is exceptional [6, 7]. A 50-year-old female with a two-week history of flu-like symptoms and with no previous history of systemic, neurological or vaccination-related illness was evaluated on 20 October 1998 because of a progressive one-week clinical picture of severe predominantly right sided proprioceptive ataxia, dysaesthesia in the legs which were painful to touch, sensation of submammary pressure, continuous icy coldness and roughness in the legs, as if the skin were covered in horsehair, and roughness on the soles of the feet. Physical examination confirmed the presence of a thoracic D2-4 sensory level for all sensory modalities, absence of weakness and extensor plantar responses in the right leg. During admission the patient began to experience vivid, spontaneous episodes of sensation as if her right leg were rising from the bed or crossing over the other leg. These intermittent episodes resolved without treatment after seven days. The following serological tests were negative: hepatitis B and C, rheumatoid factor, ANA, p-cANCA, anticardiolipin autoantibodies, lues, borrelia, Brucella mellitensis, Lyme disease, Mycoplasma pneumoniae, varicella zoster, Epstein-Barr and herpes simplex virus. MRI of the dorsal spinal cord revealed a highintensity lesion on T-2 weighted images at D2-D4 levels, which, after administration of gadolinium, showed irregular uptake with hypodense areas. It was suggested that this could be a glial expanding process. An open biopsy revealed an extensive sharply-demarcated demyelinated area (Fig. 1). Cranial MRI was normal. A 99mTc-HMPAOSPECT (23 November 1998), LETTER TO THE EDITORS

Back to table of contents Previous article Next article LettersFull AccessPersonality Disorder Related To an Acute Orbitofrontal Lesion in Multiple SclerosisLorna Galleguillos, M.D., Teresa Parrao, P.S., and Carolina Delgado, M.D.Lorna GalleguillosSearch for more papers by this author, M.D., Teresa ParraoSearch for more papers by this author, P.S., and Carolina DelgadoSearch for more papers by this author, M.D.Published Online:1 Oct 2011https://doi.org/10.1176/jnp.23.4.jnpe7AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: A 19-year-old woman with relapsing–remitting multiple sclerosis experienced subacute behavioral changes, with disinhibition, impulsiveness, and conversion drop attacks, which were related to acute lesions in the right orbitofrontal cortex. Although drop attacks remitted, her poor impulse-control persisted, suggesting an organic personality disorder. Neuropsychiatric symptoms in multiple sclerosis (MS) usually form part of a chronic psychiatric disorder, but they may also have a subacute temporal course.Case ReportThe patient was a 19-year-old woman high school graduate with relapsing and remitting MS that started with symptoms at age 15. She did not have any previous history of psychiatric disease. In February of 2009 she began to show irritability and emotional fluctuations; she abandoned her university education, and started to live a libertine life that generated serious conflicts with her parents. She acted impulsively, without respect for social limits or circumstances, and had disinhibited and childish behavior. About 1 month later, her actions became increasingly bizarre, and she began to have frequent drop attacks without impairment of consciousness. These attacks were associated with intense anxious feelings that lasted a few minutes. She was hospitalized 1 month after the symptoms began. No focal signs were found in the neurological examination. Serum test and electroencephalography were normal. Brain MRI showed new hyperintense T2 lesions, one in the right orbitofrontal gyrus, with gadolinium enhancement, and a non-enhancing lesion in the left amygdala. She was treated with intravenous methylprednisolone 1 g/day for 3 days; aripiprazole 15 mg/day, and sertraline 50 mg/day for 1 month. The drop attacks remitted completely with the treatment, but her poor impulse-control and emotional instability persisted. Subsequently, she began to cut her forearms with sharp objects, without suicidal intention. A psychiatric evaluation done after the hospitalization concluded that she had an organic personality disorder.DiscussionAlthough many of the symptoms that were shown by our patient are compatible with the main features of a borderline personality disorder (impulsivity, emotional instability, dissociation, self-injuring behavior), their beginning was temporally related to new brain lesions, and had a subacute temporal course with partial remission after 2 months. Thus, these symptoms are very likely to be secondary to a relapse of multiple sclerosis. As the majority of cases reported of relapses with neuropsychiatric symptoms, the psychiatric morbidity persisted, making a great impact in the patient's social functioning.1 Using the five-factor model of personality, it had been found that personality traits in MS are correlated with executive dysfunction2 and euphoria.3 This gave rise to the theory of a frontal syndrome as the origin of personality disorders.2 This is complementary with the results of another study finding that hypometabolism in the right orbito-frontal cortex and parahippocampal gyrus were related to the “psychotic variant of personality maladaptation in MS.”4 The orbito-frontal cortex is essential for regulating social interactions, and its lesions have been significantly related to behavioral abnormalities, euphoria, and impulsiveness, constituting an “orbito-frontal syndrome,” like our patient's behavior. Lesions in the frontal and left temporal cortex had been consistently found in other cases of MS with psychiatric relapses,1,5 but, as far as we know, this is the first report of a psychiatric relapse related to a gadolinium-enhancing lesion in the orbito-frontal cortex.Departamento de Neurología y NeurocirugíaDirección de Investigación Clínica Hospital Clínico Universidad de Chile Santiago, Chilee-mail: [email protected]uchile.cl1. Lo Fermo S , Barone R , Patti F , et al.: Outcome of psychiatric symptoms presenting at onset of multiple sclerosis: a retrospective study. Mult Scler 2010; 16:742–748Crossref, Medline, Google Scholar2. Benedict RHB , Priore RL , Miller C , et al.: Personality disorder in multiple sclerosis correlates with cognitive impairment. J Neuropsychiatry Clin Neurosci 2001; 13:70–76Link, Google Scholar3. Fishman I , Benedict RHB , Bakshi R , et al.: Construct validity and frequency of euphoria sclerotica in multiple sclerosis. J Neuropsychiatry Clin Neurosci 2004; 16:350–356Link, Google Scholar4. Reznikova TN , Terent'eva IY , Kataeva GV : Variants of personality maladaptation in patients with multiple sclerosis. Neurosci Behav Physiol 2007; 37:747–754Crossref, Medline, Google Scholar5. Ashagr-Ali AA , Taber KH , Hurley RA , et al.: Pure neuropsychiatric presentation of multiple sclerosis. Am J Psychiatry 2004; 161:226–231Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited ByPsiquiatría Biológica, Vol. 23, No. 3 Volume 23Issue 4 Fall 2011Pages E7-E7 Metrics PDF download History Published online 1 October 2011 Published in print 1 October 2011

IntroductionAgitation, mental illness, and delirium are common reasons for older adults to seek care in the emergency department (ED). There are significant knowledge gaps in understanding how to best screen older adults for these conditions and how to manage them. In addition, in areas where research has been performed, implementation has been slow. A working group convened to develop a set of high-priority research questions that would advance the understanding of optimal management of older adults with acute behavioral changes in the ED. This manuscript is the product of a breakout session on “Special Populations: Agitation in the Elderly” from the 2016 Coalition on Psychiatric Emergencies’ first Research Consensus Conference on Acute Mental Illness.MethodsParticipants were identified with expertise in emergency medicine (EM), geriatric EM, and psychiatry. Background literature reviews were performed prior to the in-person meeting in four key areas: delirium; dementia; substance abuse or withdrawal; and mental illness in older adults. Input was solicited from all participants during the meeting, and questions were iteratively focused and revised, voted on, and ranked by importance.ResultsFourteen questions were identified by the group with high consensus for their importance related to the care of older adults with agitation in the ED. The questions were grouped into three topic areas: screening and identification; management strategies; and the approach to delirium.ConclusionIt is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes, have the tools to screen older adults for those causes, and employ methods to treat the underlying causes and ameliorate their symptoms. Answers to the identified research questions have great potential to improve the care of older adults presenting with behavioral changes.

COVID-19 is associated with new symptoms of multiple sclerosis that are prevented by disease modifying therapies

To identify early clinical and MRI predictors of non-response to interferon (IFN) treatment in multiple sclerosis (MS). In 172 patients with relapsing-remitting MS treated with IFNβ, we evaluated prediction of future treatment non-response. Candidate predictors comprised disability and its sustained progression, relapse score (combining frequency and severity of relapses), brain volume change, brain parenchymal fraction, number of new T2 lesions, and T2 and T1 lesion volume within the initial year of treatment. Treatment non-response was evaluated as confirmed disability progression or overall average annual relapse score exceeding 1 over the following 5years. Logistic regression model was adjusted for patient age, gender, disease duration and changes in treatment. Ninety patients (52%) reached the status of IFN non-responders in years 2-6. Patients with ≥1 new T2 lesion and relapse score ≥2 (odds ratio ≥5.7) or those with ≥3 new T2 lesions regardless of the relapse score (odds ratio=3) were in a significantly higher risk of future treatment non-response. In patients with MS treated with IFNβ for 1year, number of new T2 lesions and annualized relapse score predict individual risk of treatment non-response over the following 5years.

MULTIPLE SCLEROSIS AFTER COVID-19: A SIGN OF THINGS TO COME?

This study explores the roles which individuals with multiple sclerosis (MS) ascribe to physical activity (PA). PA is becoming more heavily promoted by health care providers to individuals with MS due to the evidence of improved health outcomes with PA participation. However, there are possible negative outcomes with the medicalisation of PA (e.g. increased guilt over inactivity, constrained views of PA) that may be compounded by the uncertain nature of having MS and negotiating a disabled identity. Framing disability and impairment within a social-relational model of disability, we undertook an interpretative phenomenological analysis (IPA) of 15 semi-structured interviews conducted among adults with MS who had recently experienced a relapse. Our purpose was to understand how persons with MS describe the roles of PA and exercise as part of daily life with MS, relapses and disability identity. Our analysis indicated that PA occupies several roles related to MS and relapse. These roles were categorised into three main themes: PA has a paradoxical role in MS relapse; PA has a role in guilt and empowerment; and PA as defiance of disability. The roles that exercise/PA take may inform the negotiation of disability identity for individuals with MS by providing ambiguous control ‘over’ MS relapses and over impairment/disability. When not engaging in PA, our participants described feelings of guilt, worrying that increased impairment/disability would be their ‘fault.’ Because of this, PA should be promoted carefully as it occupies many important and sometimes conflicting roles in the life of an individual with MS.

Background: Very little is known regarding the impact of post traumatic stress disorder (PTSD) on the course of multiple sclerosis (MS). Objectives: To explore the impact of pre-existing PTSD on MS relapses, magnetic resonance imaging (MRI) activity, and disability in a large population-based cohort. Methods: Military Veterans with MS and PTSD prior to symptom onset (MSPTSD, n = 96) were identified using the Department of Veterans Affairs MS databases. MSPTSD cases were matched to MS controls without PTSD (n = 95). Number of relapses, number of new T2 lesions and new gadolinium lesions on brain MRI, and neurological disability were abstracted between 2015 and 2019. Results: The mean annualized relapse rate was greater in the MSPTSD group versus controls (0.23 vs 0.06, respectively; p < 0.05), as was the annualized mean number of new T2 and gadolinium-enhancing lesions on brain MRI (0.52 vs 0.16 and 0.29 vs 0.08, respectively; p < 0.05). Disability accrual (time to Disability Status Scale 6.0) was more rapid (23.7 vs 29.5 years, p < 0.05) in relapsing MS patients with PTSD. Conclusion: Patients with MSPTSD have higher disease activity and reach disability endpoints more rapidly than controls. This is the first study to show PTSD as a potentially modifiable risk factor for MS relapses, MRI activity, and disability.

Dysphagia is one of the most common symptoms in multiple sclerosis (MS) patients. It can reduce the quality of life and increase the risk of mortality by developing complications such as aspiration pneumonia. The present study was conducted to estimate the prevalence of dysphagia in MS patients and investigate the associations between dysphagia and disease characteristics. The Persian version of the DYMUS questionnaire was used to assess dysphagia in 865 patients with MS, including 738 (85.3%) relapsing-remitting MS (RRMS), 106 (12.3%) secondary progressive MS (SPMS), and 21 (2.4%) primary progressive MS (PPMS). Also, demographic and clinical data, including age, sex, smoking status, Expanded Disability Status Scale (EDSS) score, disease duration, disease-modifying therapies exposure, initial symptoms of MS, were recorded. The mean (SD) age was 37.95(9.25) years, and 83.1% of the participants were female. The prevalence of dysphagia was estimated to be 25.4% among all patients. According to the DYMUS questionnaire results, the prevalence of dysphagia in RRMS, SPMS, and PPMS patients was 22.2%, 44.3%, and 42.9%, respectively. After multivariate analysis the current EDSS score (OR = 1.197, CI: 1.062, 1.350, p = 0.003), cerebellar impairment (OR = 1.335, CI: 1.450, 4.716, p = 0.004) and motor dysfunction (OR = 1.651, CI: 1.004, 2.715, p = 0.048) emerged as the risk factors for dysphagia. Since dysphagia, as previously mentioned, is a common symptom in multiple sclerosis, particularly in SPMS and PPMS courses, active screening for this condition is recommended in all patients, particularly those with identified risk factors.