A patient with Marchiafava–Bignami disease as a complication of diabetes mellitus treated effectively with cortico steroid

Risk factors and dynamic nomogram for unfavorable prognosis of Marchiafava-Bignami disease

OBJECTIVE

Most patients with Marchiafava-Bignami disease (MBD) had unfavorable prognosis, with disability or death. We aimed to determine the risk factors of early unfavorable prognosis of MBD, and to develop a predictive nomogram for early unfavorable prognosis of MBD.

METHODS

MBD patients admitted to our hospital between 1 January 2013 and 31 December 2021 were included. Unfavorable prognosis was defined as mRS score ≥3, the independent risk factors for unfavorable prognosis of MBD with the odds ratio (OR) and 95% confidential interval (CI) acquired by multiple logistic regression were included in development of the predictive nomogram for early unfavorable prognosis of MBD, and the area under curve (AUC) of the receiver operating characteristic curve was calculated. The published case reports of MBD were used as the external validation group to verify the predictive ability of the nomogram.

RESULTS

Independent risk factors for early unfavorable prognosis of MBD included Glasgow Coma Scale score (OR = 0.636, 95% CI = 0.506-0.800, p = 0.004) and pneumonia (OR = 2.317, 95% CI = 1.003-5.352, p = 0.049). The AUC of the nomogram was 0.852. Ninety-four case reports, a total of 100 cases of MBD were included as the external validation group, its AUC was 0.840. The online dynamic nomogram for early unfavorable prognosis of MBD was constructed.

INTERPRETATION

It is confirmed by external validation that the nomogram has a preferable predictive ability and clinical efficacy, and the dynamic online predictive nomogram is helpful for physicians to quickly assess the prognosis of MBD.

From Mild Gait Difficulties to a Sudden Coma: A Rare Case of Marchiafava-Bignami Disease

ABSTRACT

In this case report we describe the case of a 66-year old man with subacute gait difficulties, with a progression to confusion coma with multiple generalised epileptic seizures during the following days. Biochemical analysis showed hyperglycaemia, cerebrospinal fluid (CSF) testing showed a mild lymphocytic pleocytosis and an elevated protein and lactate. Broad-spectrum antibiotics and antiviral therapy where initiated. However, all other CSF testing remained negative. Magnetic resonance imaging of the brain showed remarkably symmetric hyperintense T2 white matter lesions most noticable in the corpus callosum. The lesion pattern was suggestive of a metabolic or toxic encephalopathy, the preponderance for the corpus callosum was furthermore suggestive for Marchiafava-Bignami disease (MDB), as was the clinical course since admission of the patient. A high dose IV substitution of vitamin B1, B6 and B12 was started and antibiotic and antiviral therapy was discontinued. After one day the patient showed progressive regaining of consciousness and he returned to premorbid functioning in a matter of 1-2 weeks. MRI of the brain after 1 week showed notable improvement of the white matter lesions. At routine follow-up two weeks later he presented with icterus and a diagnosis of Epstein-Barr virus (EBV) hepatitis was made, lymph node biopsies showed an EBV positive diffuse large cell B-cell lymphoma (DLCBL). MDB is mostly associated with severe alcoholism, with malnourishment being the second leading cause, however there are case reports describing MDB in patients with chronically poorly controlled diabetes mellitus. We hypothesize that his condition may have been precipitated by his poorly controlled diabetes mellitus. However it is also possible that weight loss (probably related to the DLCBL diagnosis) might have contributed to a state of malnourishment and therefore played a role in the aetiology as well.

Marchiafava Bignami Disease: A Rare Neurological Complication of Long-Term Alcohol Abuse

Marchiafava Bignami disease is a demyelinating and necrotic disease of the central nervous system in chronic alcohol users and malnourished patients. The primary characteristic lesion of this disease is present in the corpus callosum in the form of its necrosis, but plenty of evidence suggests that it can also affect other parts of the brain. The main pathophysiology revolves around the consumption of alcohol and its ability to cause thiamine depletion in the body and hinder various metabolic pathways. There is also a hindrance in myelin synthesis, which further damages the signal transmission leading to an array of symptoms and signs. It is present in different degrees in patients in the form of different stages, namely acute, subacute, and chronic. The diagnosis of the disease becomes tough as the presenting symptoms are very generic and vague. Before the innovation of advanced imaging techniques, it was mainly a finding during an autopsy, but presently it can be diagnosed by a well-taken history and imaging techniques which can help to rule out other diseases having a similar clinical presentation. The gold standard for the diagnosis of the disease is using magnetic resonance imaging (MRI) techniques to visualize the lesions present in the corpus callosum and other areas, but other methods like computed tomography (CT) are also used. The prognosis of the disease is influenced by many factors, and it varies greatly. Some factors such as broad involvement of the cerebral cortex and severe disturbances in consciousness are indicative of a poor prognosis. The differential diagnosis consists of other alcohol use disorders like Wernicke's encephalopathy, neoplastic conditions, and multiple sclerosis, to mention a few. Each one should be carefully eliminated before finalizing the diagnosis. The treatment of the disease is not concrete, but evidence shows improvement with specific interventions.

Amantadine as a Potential Treatment for Marchiafava–Bignami Disease: Case Reports and a Possible Mechanism

Introduction

Several reports have described the use of amantadine for managing symptoms in Marchiafava–Bignami disease (MBD); however, amantadine's role for the treatment of MBD symptoms is unclear. Here, we describe 2 patients with MBD who were treated with amantadine and hypothesize a potential mechanism responsible for clinical benefit. Case 1. A 38-year-old woman with excessive wine drinking presented with agitation, impaired speech, and a minimally conscious state. MRI revealed lesions in the splenium and genu. After being diagnosed with MBD, she was treated with intravenous thiamine, multivitamins, and 100 mg of amantadine twice a day for 2 weeks. She recovered to near baseline after 3 weeks. Case 2. A 54-year-old woman with years of heavy alcohol use presented with sudden bradyphrenia, acalculia, disinhibited behavior, weakness, and urinary incontinence. MRI revealed a large anterior callosal lesion. Two years after initial recovery from MBD, she noted that consuming “energy drinks” resulted in a transient, near-complete resolution of her residual behavioral, fatigue, and language symptoms. 100 mg of amantadine twice a day was trialled. After noted improvement, a further escalation to 200 mgs 3 times a day resulted in significant improvement in language and behavioral symptoms.

Conclusion

Amantadine in addition to vitamins may be beneficial in the treatment of MBD. It is possible that the dopaminergic effect of amantadine leads to improved recovery and function in dopamine-mediated pathways, including mesocortical and mesolimbic pathways during initial recovery, as well as improved speech, behavior, and fatigue in the following months. The role of amantadine in the treatment of MBD warrants further study.

Neuroimaging Pearls from the MDS Congress Video Challenge. Part 2: Acquired Disorders

The MDS Video Challenge continues to be the one of most widely attended sessions at the International Congress. Although the primary focus of this event is the presentation of complex and challenging cases through videos, a number of cases over the years have also presented an unusual or important neuroimaging finding related to the case. We reviewed the previous Video Challenge cases and present here a selection of those cases which incorporated such imaging findings. We have compiled these "imaging pearls" into two anthologies. The first focuses on pearls where the underlying diagnosis was a genetic condition. This second anthology focuses on imaging pearls in cases where the underlying condition was acquired. For each case we present brief clinical details along with neuroimaging findings, the characteristic imaging findings of that disorder and, finally, the differential diagnosis for the imaging findings seen.

Marchiafava-Bignami disease with haemophagocytic lymphohistiocytosis as a postoperative complication of cardiac surgery

Marchiafava-Bignami disease (MBD) is a rare complication of chronic alcoholism; however, MBD in a non-alcoholic diabetic patient has rarely been reported. The aetiology or pathophysiology of MBD is still unknown. A 50-year-old man with a history of untreated diabetes mellitus underwent on-pump beating coronary artery bypass graft surgery (CABG) surgery for three-vessel and left main coronary disease. 3 days after the surgery, he developed a fever over 40°C and entered a coma state. MRI revealed multiple lesions, including in the corpus callosum, globus pallidus, brain stem and upper cervical spinal cord, which suggested MBD. The patient did not respond to thiamine therapy, but partly responded to steroid therapy. He ultimately died of respiratory failure. The autopsy revealed MBD and haemophagocytic lymphohistiocytosis. It is rare, but systemic inflammatory response syndrome induced by on-pump beating CABG could develop these complication.

Vegetarian diet and excessive tea consumption: a dangerous association?

Rare metabolic diseases may sometimes arise acutely and endanger human life if not immediately recognized and treated. Marchiafava Bignami disease is an uncommon neurologic disorder described in alcohol abusers and characterized by an acute severe damage of brain white matter. Even more rarely, it has been reported in non-alcohol addicted patients, but never in vegetarian people. This is a case report of a young vegetarian woman, accustomed to drink high amounts of tea, who, three weeks after her first natural childbirth, developed serious motor and cognitive disturbances. A timely brain magnetic resonance (MR) allowed us to identify Marchiafava Bignami disease and she healed few hours after the administration of parenteral steroids and vitamins. We advise to suspect Marchiafava Bignami Disease in all patients presenting with non-obvious acute generalized motor and cognitive disturbances, also if non alcoholics, and to collect the nutritional habits in all patients with suspected symptoms. In these cases a timely brain MRI is warranted, since brain imaging is typical and patients may recover after a prompt treatment.

Marchiafava-Bignami disease with rare etiology: A case report

A male, 62-year-old patient was admitted to hospital due to dizziness and gait disturbance for 10 days. The patient had fallen a few times due to the gait instability, which was associated with stiffness and memory loss. The patient had undergone cardiac carcinoma surgery three years previously and had no drinking history. Physical examination revealed that the patient was lucid when conscious but exhibited slurred speech, apathy and cognitive impairment. The finger-to-nose and rapid alternating movement tests showed the patient to be slightly clumsy. Magnetic resonance imaging revealed symmetric abnormal signals in the splenium of the corpus callosum, and the diagnosis was Marchiafava-Bignami disease (MBD). The patient recovered following the administration of vitamin B and other treatments. The patient had long-term appetite loss. A brain myelin metabolism disorder caused by long-term malnutrition and leading to demyelinating changes in the brain may have been the cause of the MBD of this patient. Clinicians should increase awareness of this disease and should not ignore the diagnosis of it, even when the patient lacks a drinking history. Early diagnosis and treatment can improve the prognosis of the patient.

Marchiafava-bignami disease in a nonalcoholic diabetic patient

Marchiafava-Bignami disease (MBD) is a rare neurological disorder mostly seen in alcoholic and malnourished patients with a pathognomonic hallmark of corpus callosum demyelination. MBD in nonalcoholics without malnutrition has rarely been reported. We report a case of MBD in a diabetic patient, without alcoholism or malnutrition, caused by a wide range of glycemic level fluctuations. A 38-year-old man presented with sudden onset of alteration in speech and multiple falls in three days. Neurologic examination showed dysarthria, dysmetria, and ataxia but, otherwise, normal cranial nerves, motor and sensory functions, and tendon reflexes. Brain MRI showed symmetric abnormalities in the splenium of the corpus callosum. In addition, demyelination was also observed in bilateral posterior limbs of the internal capsule and brachium ponti. His symptoms significantly improved after stabilization and normalization of his plasma glucose level and administration of multivitamins and corticosteroids. The underlying pathophysiology of the development of MBD in our case is likely to be osmotic stress from a wide range of glycemic fluctuations causing structural and functional disturbance of oligodendrocytes, which may be reversible in its early stage.