A challenging diagnosis of late-onset tumefactive multiple sclerosis associated to cervicodorsal syringomyelia: doubtful CT, MRI, and bioptic findings: Case report and literature review

Clinical and Epidemiological Aspects of Late Onset Multiple Sclerosis in East-Azerbaijan, Iran; A Population-Based Study

BACKGROUND

Late-onset multiple sclerosis (LOMS) is defined as symptoms initiating at an age above 50.

Objective

This study aims to determine the clinical and epidemiological aspects of LOMS in East-Azerbaijan province, Iran.

METHODS

This population-based study recruited nearly all MS patients to the end of 2020, who were diagnosed at age≥50, by referring to the only local MS registry center. We investigated prevalence, sex, age-of-onset, first clinical presentation, family history, and gap of diagnosis. Also, we compared the disease characteristics between male and female cases.

RESULTS

Out of 4905 total cases of MS, 217 cases (4.42%) were LOMS. The mean age of onset was 53.80±3.41 years with a maximum age of 68 years. The most common age group of the patients was 50 to 55 years (69.1%). The frequency by sex of LOMS in females (150) was greater than males (67). Positive family history was seen in 6.17%, and in 41% of the patients, the disease was diagnosed in a timely manner. Early symptoms were motor (31.3%), sensory (24.8%), optic neuritis (23%), cerebellar symptoms (13.8%), and brainstem symptoms (6.9%). The first presentation of the disease was different between male and female cases (P-value<0.01). Motor symptoms were the most prevalent first clinical presentation in female cases (37.6%), while in male cases, cerebellar symptoms (25.8%) were the most common.

CONCLUSION

LOMS is not a rare condition. Increasing knowledge in the diagnosis, as well as increasing awareness of the disease in the general population, leads to early diagnosis of LOMS and prevention of consequences.

Clinical Features of Late-Onset Multiple Sclerosis: a Systematic Review and Meta-analysis

BACKGROUND

Multiple sclerosis (MS) commonly affects young adults at the ages 20 to 40 years old, but it can onset at each age. Late-onset multiple sclerosis (LOMS) is defined as symptoms initiating after the age of 50. Misdiagnosis and a remarkable gap in diagnosis of LOMS is a challenge of the elderly population so in this article we described the proportion of LOMS and the clinical features and phenotype of the disease in this age group.

METHODS

After registration of the study protocol, an electronic search was performed in 3 databases and for full coverage of the published studies, we also checked the references of each related article. Two independent researchers screened the records in title/abstract and full-text stages and extracted the data using a data extraction table. The risk of bias was assessed using Joanna Briggs Institute checklist and meta-analysis was conducted by CMA 2. Only the studies with 50 years old cut-off and using McDonald or Poser diagnostic criteria were included in the meta-analysis.

RESULTS

After removing duplicated studies, out of 733 results of electronic and hand searching, 31 studies met our inclusion criteria for the systematic review, and 11 of them were included in the quantitative synthesis. With different cut-offs and diagnostic methods 1.1% to 21.3% proportion of LOMS, has been reported in the studies. Meta-analysis reached a 5.01% (95% CI: 3.78% to 6.57%), proportion of LOMS in total MS cases. The female cases were more than males (range between 57.7% to 70.2%) and 64.46% (95% CI: 61.94% to 66.91%) proportion of females has been found in this study. 65.00% (95% CI: 44.71% to 81.02%) proportion of spinal cord involvements and 49.80% (95% CI: 39.28% to 60.24%) proportion of relapsing-remitting multiple sclerosis (RRMS) was also observed in LOMS cases. In 4 of included studies, the progressive form was the predominant phenotype. The most prevalent first disease presentation of LOMS was motor dysfunction (ranges between 100% to 35.4%) followed by sensory problems (ranges between 94% to 5%), visual symptoms (ranges between 22.9% to 5%), and brainstem dysfunction (ranges between 25% to 12.3%). The proportion of positive oligoclonal band (OCB), was varied from 46% to 98% in different studies and positive immunoglobulin G (IgG) index also was seen in 45.04% and 66% of the patients. 2.2% - 12.5% of the LOMS cases had a positive family history.

CONCLUSION

In about 5% of cases, MS can be diagnosed at ages above 50 years old. There is an increasing concern of a more progressive form of MS in LOMS cases. Unlike the adult-onset MS, the first presentation of LOMS is usually motor dysfunction. Understanding the proportion and clinical features of LOMS will help clinicians with the diagnosis of MS in this age group and prevention of wrong management plans and complications in these patients. Although the proportion of females is still more than males in LOMS cases; but there is a trend to increase in male cases with aging.

A Blind Spot in the Diagnostic Field: The Challenging Diagnosis of Tumefactive Multiple Sclerosis

Tumefactive Multiple Sclerosis (TMS) is a rare variant with 1 per 1000 cases of MS and 3 per million cases per year. TMS can mimic clinical and radiological features of a neoplasm, infarction, or abscess and therefore can be diagnostically challenging for clinicians. We present a clinical scenario of a patient presenting with left homonymous hemianopia with atypical radiological features initially thought to be more consistent with neoplasm or infraction. Ultimately, biopsy was done which led to the diagnosis of tumefactive multiple sclerosis.

Progression of tumefactive demyelinating lesion in a child demonstrated with MRI

Tumefactive demyelinating lesions (TDLs) are atypical presentations of various demyelinating diseases. They can mimic brain tumors in their clinical and radiological features and usually respond favorably to corticosteroid therapy. We report a case of a 17-year-old girl with a single TDL suddenly increasing in size even under steroid therapy. She underwent very strict follow-up examinations with conventional magnetic resonance and diffusion-weighted imaging, perfusion-weighted imaging, proton-magnetic resonance spectroscopy. The behavior of the lesion during the different follow-up sessions posed a diagnostic challenge as it expanded its size during the final examination, in stark contrast to what we forecast. Diagnosis of TDL was initially hypothesized, but the aggressive behavior of the lesion required biopsy.

Multiple cerebral gliomas mimicking central nervous system inflammatory demyelinating diseases: A rare case with review of literature

RATIONALE

Multiple cerebral gliomas (MCGs), usually classified into multifocal and multicentric subtypes, represent major diagnostic challenges as their clinical, radiologic, and pathohistological features are not uniform, often mimicking brain metastatic tumors or central nervous system inflammatory demyelinating diseases (IDD).

PATIENT CONCERNS

Here, we report a rare case of MCGs with isolated seizures and 4 lesions in the brain, that was initially misdiagnosed as IDD during treatment.

DIAGNOSIS

The pathological diagnosis was astrocytoma, which was classified as a World Health Organization grade II glioma.

INTERVENTIONS

The patient was treated with dexamethasone and sodium valproate when he was misdiagnosed as having IDD. After the pathological diagnosis was obtained, he was treated with temozolomide and radiotherapy.

OUTCOMES

Three months after the above treatment, the health of the patient had improved; he was asymptomatic, and presented with better radiological manifestations.

LESSONS

Diagnostic imaging is valuable in differential diagnosis. Magnetic resonance spectroscopy is a promising technique for the assessment and characterization of lesions, though its role in definitive diagnosis is not yet defined. Brain tissue biopsy remains the golden standard for definitive diagnosis. In China, for various reasons, craniotomy biopsy is not performed routinely in patients with multiple intracranial lesions, and stereotactic cranial biopsy may be a more viable option because of its safety and cost-effectiveness. In summary, this case demonstrates that MCGs need to be included in the differential diagnosis of unknown intracranial multiple lesions.