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Not The Classic Waxing and Waning Multiple Sclerosis: A Case Report
Cinthia Reyes1, John Coleman1, Andrew Rennick1
1Department of Internal Medicine University of Miami at Holy Cross.
Abstract:
Multiple sclerosis (MS) is a chronic demyelinating disease, more common in females, typically presenting with sensory disturbances, motor weakness, and visual deficits. This case describes an atypical presentation in a male with ascending sensory deficits and an incidental spinal syrinx. We present 43-year-old male with no prior medical history developed a one episode of progressive paresthesia over several months, rapidly ascending to the umbilical region with urinary difficulties and gait instability. Magnetic Resonance Imaging (MRI) revealed scattered demyelinating brain lesions and a spinal syrinx from C5-T12 with an intramedullary lesion at T8. Cerebrospinal fluid (CSF) analysis confirmed oligoclonal bands, supporting an MS diagnosis. The patient improved with high-dose corticosteroids and was discharged with neurology follow-up. This case highlights the diagnostic challenge of MS in the presence of a syrinx, a rare finding in MS (4.5% prevalence). Clinicians must differentiate MS from other etiologies, adhere to McDonald criteria, and recognize that imaging findings should not overshadow clinical judgment in diagnosing MS.
Insights
This case study details an unusual male presentation of Multiple Sclerosis (MS) with ascending sensory deficits and a spinal syrinx. Early diagnosis and treatment are crucial for managing this rare neurological condition.
Area of Science:
- Neurology
- Neuroimmunology
Background:
- Multiple sclerosis (MS) is a chronic, demyelinating central nervous system disease.
- MS predominantly affects females and typically presents with sensory, motor, or visual symptoms.
Observation:
- A 43-year-old male presented with atypical ascending sensory deficits and gait instability.
- Incidental findings included scattered demyelinating brain lesions and a spinal syrinx (C5-T12).
Findings:
- Cerebrospinal fluid (CSF) analysis revealed oligoclonal bands, confirming an MS diagnosis.
- The patient showed improvement with high-dose corticosteroids.
Implications:
- This case underscores the diagnostic challenges of MS, particularly with rare co-occurring conditions like spinal syrinx.
- Differentiating MS from other etiologies and integrating clinical judgment with imaging findings are critical for accurate diagnosis.
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