Letter to the Editor
Atypic onset of multiple sclerosis mimicking Susac's Syndrome
Presentación atípica de esclerosis múltiple que imita el síndrome de Susac
Read
2
Timeswas read the article
0
Total PDF
2
Total HTML
Share statistics
array:23 [ "pii" => "S0025775323007601" "issn" => "00257753" "doi" => "10.1016/j.medcli.2023.11.025" "estado" => "S300" "fechaPublicacion" => "2024-04-26" "aid" => "6514" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2023" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2024;162:404-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:18 [ "pii" => "S0025775323006668" "issn" => "00257753" "doi" => "10.1016/j.medcli.2023.09.025" "estado" => "S300" "fechaPublicacion" => "2024-04-26" "aid" => "6470" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Clin. 2024;162:406" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Image in medicine</span>" "titulo" => "Bleomycin-induced flagellate dermatitis in a patient with Hodgkin lymphoma" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "406" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Dermatitis flagelada causada por bleomicina en un paciente con linfoma de Hodgkin" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 864 "Ancho" => 1340 "Tamanyo" => 105121 ] ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Nicolò Danesin, Alessandro Cellini, Francesco Piazza, Livio Trentin, Andrea Visentin" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Nicolò" "apellidos" => "Danesin" ] 1 => array:2 [ "nombre" => "Alessandro" "apellidos" => "Cellini" ] 2 => array:2 [ "nombre" => "Francesco" "apellidos" => "Piazza" ] 3 => array:2 [ "nombre" => "Livio" "apellidos" => "Trentin" ] 4 => array:2 [ "nombre" => "Andrea" "apellidos" => "Visentin" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775323006668?idApp=UINPBA00004N" "url" => "/00257753/0000016200000008/v2_202404281220/S0025775323006668/v2_202404281220/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0025775323007121" "issn" => "00257753" "doi" => "10.1016/j.medcli.2023.11.012" "estado" => "S300" "fechaPublicacion" => "2024-04-26" "aid" => "6497" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2024;162:403-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta al Editor</span>" "titulo" => "Escabiosis resistente a permetrina" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "403" "paginaFinal" => "404" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Permethrin-resistant scabies" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Mar Luque-Luna, Lluís Corbella-Bagot, Priscila Giavedoni" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Mar" "apellidos" => "Luque-Luna" ] 1 => array:2 [ "nombre" => "Lluís" "apellidos" => "Corbella-Bagot" ] 2 => array:2 [ "nombre" => "Priscila" "apellidos" => "Giavedoni" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020624001177" "doi" => "10.1016/j.medcle.2024.04.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020624001177?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775323007121?idApp=UINPBA00004N" "url" => "/00257753/0000016200000008/v2_202404281220/S0025775323007121/v2_202404281220/es/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Atypic onset of multiple sclerosis mimicking Susac's Syndrome" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "404" "paginaFinal" => "405" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Asuman Orhan Varoglu, Mehmet Akif Balci, Basak Atalay" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Asuman" "apellidos" => "Orhan Varoglu" "email" => array:1 [ 0 => "asumanorhan69@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Mehmet Akif" "apellidos" => "Balci" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Basak" "apellidos" => "Atalay" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Neurology, Medical School, Istanbul Medeniyet University, Istanbul, Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Radiology, Medical School, Istanbul Medeniyet University, Istanbul, Turkey" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Presentación atípica de esclerosis múltiple que imita el síndrome de Susac" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 555 "Ancho" => 1674 "Tamanyo" => 116812 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Sagittal T2-weighted (T2W) images reveal hyperintense lesions in the periventricular region, left cerebellar hemisphere, and corpus callosum. Furthermore, bilateral polymicrogyria is demonstrated involving both cerebral hemispheres. These lesions exhibit no enhancement following intravenous contrast agent administration (not illustrated). (b) Axial T2-weighted (T2W) images depict the presence of new lesions in the right middle cerebellar peduncle and the superior frontal subcortical white matter. The middle cerebellar pedincule shows contrast enhancement. (c) 3D CUBE FLAIR, the spinal cord lesion at the C2 cervical vertebra level is highlighted with white arrows.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A triplet of encephalopathy, BRAO, and hearing loss defines SS.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> SS primarily affects young women. Early diagnosis is crucial since late therapy can have serious, permanent side effects. MRI findings include hyperintense, multifocal, spherical, tiny lesions, at least one of which is in the CC (sometimes known as a “snowball”) on T2 (or FLAIR).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> Lesions touching ventricles and CC in MS, however, round lesions, at least one, located in CC in SS.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> Our patient mimicked SS initially because of encephalopathy, epilepsy, and round-shaped lesions in the CC and CS. We describe a female MS patient with polymicrogyria and an unusual initial presentation that mimics SS. A 21-year-old female has been admitted due to fever, encephalopathy, convulsion, cold, and flu symptoms, for 4 days. Cooperation and orientation disorder, apathy, and tetraparesis (3–4/5) were determined. Serum biochemical parameters and Cerebrospinal fluid analysis (CSF) for the viral panel, culture, and biochemistry were normal. MRI revealed hyperintense lesions in the periventricular region, left cerebellar hemisphere, and CC on Axial T2-weighted and Sagittal T2-weighted images. Furthermore, bilateral polymicrogyria was demonstrated involving both cerebral hemispheres (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a). No contrast enhancement was seen. Anti-myelin oligodendrocyte glycoprotein (anti-MOG), oligoclonal band, and anti-aquaporin-4 (neuromyelitis optica spectrum disease) were negative. The IgG index was 0.55. CSF showed glucose: 74<span class="elsevierStyleHsp" style=""></span>mg/dL (40–70<span class="elsevierStyleHsp" style=""></span>mg/dl), sodium (Na): 147<span class="elsevierStyleHsp" style=""></span>mmol/L (135–150<span class="elsevierStyleHsp" style=""></span>mmol/L), chloride (CL): 122<span class="elsevierStyleHsp" style=""></span>mmol/L (135–150<span class="elsevierStyleHsp" style=""></span>mmol/L), and protein: 170<span class="elsevierStyleHsp" style=""></span>mg/dL (150–450<span class="elsevierStyleHsp" style=""></span>mg/L), and no cells were observed. <span class="elsevierStyleSup">18</span>F-FDG PET/CT revealed hypometabolic lesions. MR spectroscopy showed both NAA/choline ratio and choline/creatine ratio dropped suggesting demyelination lesions. Therefore, brain tumors were excluded. No hearing loss and BRAO were found. Methylprednisolone (IVP, 1000<span class="elsevierStyleHsp" style=""></span>mg/day) therapy was initiated following the preliminary diagnosis of SS. Levetiracetam 1000<span class="elsevierStyleHsp" style=""></span>mg/day was given. On MRI, substantial regressions were seen, two weeks later. A month later, she was admitted to hospital once more same complaints. Hyperintense lesions were seen in the superior frontal subcortical WM and the right middle cerebellar peduncle (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b). New oligoclonal analysis band was positive. She was diagnosed as having atypical-onset MS. A new hyperintense lesion was discovered at C2 level in the second hospitalization (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>c). After treatment, her symptoms were regressed. She began fingolimod therapy, and no further attacks or lesions were seen for almost two years. Acute disseminated encephalomyelitis (ADEM) has a mildly increased CSF protein level and lymphocytic pleocytosis. ADEM lesions are often bigger, bilateral, asymmetric, and more numerous than MS lesions. Indistinct margins are a common imaging feature of ADEM lesions. This may make it easier to distinguish these lesions from MS lesions, which often have clear-cut edges.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> In our case, a CSF revealed no cells, and protein level was normal. Additionally, all lesions showed no contrast enhancement. So, ADEM was eliminated. Brain tumors including primary brain lymphoma were excluded by <span class="elsevierStyleSup">18</span>F-FDG PET/CT and MR spectroscopy.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> BRAO and hearing loss were not found even though she was present encephalopathy and had CS lesions and “snowball lesions” in CC seen in SS. Initially, we did not think of MS because MRI revealed hyperintense lesions mimicking SS C, moreover, all lesion's ages were the same. New lesions with contrast enhancement were seen during the second hospitalization, particularly on the right side of middle cerebellar peduncle and C2 level. Oligoclonal band was positive finally, so she was diagnosed with MS. We also demonstrated that she had bilateral polymicrogyria. There is no report of MS case with polymicrogyria. Independent of isolated lesions, although appearing to be normal, widespread alterations in Gray Matter (GM) and WM might be pathogenic.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> Although this pathophysiological process, which is ubiquitous in both GM and WM, may have an impact on one another, this impact does not have to be parallel.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> We speculated that polymicrogyria in both hemispheres changed the way that GM and WM interacted, leading to the development of atypical demyelination lesions in the WM. Therefore, the patient's initial clinical presentation and MRI findings were unusual for MS. Even at the first presentation, MS should be considered when there are cortical clinical symptoms, “snowball lesions” in the CC, and lesions in the CS.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors’ contribution</span><p id="par0010" class="elsevierStylePara elsevierViewall">Asuman Orhan Varoglu: Conception, design, supervision, data collection and/or processing, analysis and/or interpretation, literature review, writing. Mehmet Akif Balci: Data collection and/or processing. Basak Atalay: Analysis and/or interpretation, literature review.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">All data are available</span><p id="par0015" class="elsevierStylePara elsevierViewall">Written informed consent was obtained from the patient.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Funding</span><p id="par0020" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors’ contribution" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "All data are available" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Funding" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 555 "Ancho" => 1674 "Tamanyo" => 116812 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Sagittal T2-weighted (T2W) images reveal hyperintense lesions in the periventricular region, left cerebellar hemisphere, and corpus callosum. Furthermore, bilateral polymicrogyria is demonstrated involving both cerebral hemispheres. These lesions exhibit no enhancement following intravenous contrast agent administration (not illustrated). (b) Axial T2-weighted (T2W) images depict the presence of new lesions in the right middle cerebellar peduncle and the superior frontal subcortical white matter. The middle cerebellar pedincule shows contrast enhancement. (c) 3D CUBE FLAIR, the spinal cord lesion at the C2 cervical vertebra level is highlighted with white arrows.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hemorrhagic cerebral vasculopathy in Susac syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "L. Muccioli" 1 => "M. Nicodemo" 2 => "R. Rinaldi" 3 => "G. Vornetti" 4 => "L. Spinardi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s13760-021-01835-7" "Revista" => array:6 [ "tituloSerie" => "Acta Neurol Belg" "fecha" => "2022" "volumen" => "122" "paginaInicial" => "1599" "paginaFinal" => "1600" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34787817" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0030" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute disseminated encephalomyelitis and viral encephalitis: An unusual and misleading imaging" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "I. Shukla" 1 => "B. Modasia" 2 => "B. Chaurasia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ccr3.8004" "Revista" => array:5 [ "tituloSerie" => "Clin Case Rep" "fecha" => "2023" "volumen" => "11" "paginaInicial" => "e8004" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/37786457" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0035" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Correlation between white matter damage and gray matter lesions in multiple sclerosis patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "X.M. Han" 1 => "H.J. Tian" 2 => "Z. Han" 3 => "C. Zhang" 4 => "Y. Liu" 5 => "J.B. Gu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/1673-5374.206650" "Revista" => array:6 [ "tituloSerie" => "Neural Regen Res" "fecha" => "2017" "volumen" => "12" "paginaInicial" => "787" "paginaFinal" => "794" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28616036" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0040" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Brain atrophy and disability progression in multiple sclerosis patients: a 10-year follow-up study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Jacobsen" 1 => "J. Hagemeier" 2 => "K.M. Myhr" 3 => "H. Nyland" 4 => "K. Lode" 5 => "N. Bergsland" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/jnnp-2013-306906" "Revista" => array:6 [ "tituloSerie" => "J Neurol Neurosurg Psychiatry" "fecha" => "2014" "volumen" => "85" "paginaInicial" => "1109" "paginaFinal" => "1115" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24554101" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00257753/0000016200000008/v2_202404281220/S0025775323007601/v2_202404281220/en/main.assets" "Apartado" => array:4 [ "identificador" => "66430" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas al Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00257753/0000016200000008/v2_202404281220/S0025775323007601/v2_202404281220/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775323007601?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 April | 1 | 0 | 1 |
| 2024 January | 1 | 0 | 1 |
