Tumefactive Multiple Sclerosis Presenting as Ring‐Enhancing Lesions on Computerized Tomography of the Brain in a 27‐Year‐Old Man

1University of Texas Health Science Center, San Antonio, TX

Meeting: Hospital Medicine 2007, May 23-25, Dallas, Texas

Abstract number: 136

Case Presentation:

A 27‐year‐old man presented to the emergency department with 1 week of right‐hand weakness and ataxia. Three weeks earlier, he had developed flulike symptoms consisting of headache, fatigue, and nausea. He took Theraflu, but the headache and fatigue continued. One week before admission, his primary care physician gave him albuterol and an unknown antibiotic for sinusitis. He then developed right‐hand weakness and ataxia. A review of systems was negative for fevers, weight loss, sick contacts, travel, or HIV risk factors. He had no family history of CNS malignancy or multiple sclerosis. He did say he was exposed to cats at home. Aphysical exam revealed no lymphadenopathy. A neurological exam revealed ataxia, right upper extremity dysmetria and dysdiadokinesis, and sensory/motor loss of the right C8 dermatome. The lab results showed only mild leukocytosis. A CT of the brain revealed multiple ring‐enhancing lesions with minimal edema, which was confirmed by a brain MRI. Even though he had no HIV risk factors, his age, cat exposure, and radiologic studies prompted empiric treatment for toxoplasmosis while further evaluation was completed. The results of testing showed he was negative for HIV, histoplasmo‐sis, cryptococcus, coccidiomycosis, lymphoma, and toxoplasmosis. Because it was difficult to correlate his right C8 dermatome findings with his radiologic findings, a stereotactic brain biopsy was performed, revealing acute tumefactive multiple sclerosis (MS).

Discussion:

Patients often present to the hospital after an initial assessment by an outpatient physician, which may allow a disease to progress if it has not been appropriately diagnosed early. On further review, it appears that what was thought to be an isolated URI syndrome ultimately resulted in exacerbation of tumefactive MS. Moreover, because tumefactive MS and its radiographic appearance are very rare and only account for 1%‐3% of all patients with MS, diagnosis was even more challenging. The McDonald criteria for diagnosis of MS are based on dissemination of symptoms and lesions in space and time and have been revised to give more weight to clinical and MRI findings. With this in mind, the discrepancy between this patient's right C8 dermatome exam and radiographic findings led to the eventual workup and subsequent diagnosis of his disease.

Conclusions:

It is imperative to approach all clinical situations with a broad differential diagnosis. This is especially true when treating someone empirically for a common clinical presentation. In this case, empiric treatment for toxoplasmosis was initiated because of the demographic characteristics of the patient and his radiologic findings; however, attention to the results of the physical exam and the patient history ultimately led to the correct diagnosis.

Author Disclosure:

A. W. Lowery, None; M. M. Johnson, None.

To cite this abstract:

Lowery A, Johnson M. Tumefactive Multiple Sclerosis Presenting as Ring‐Enhancing Lesions on Computerized Tomography of the Brain in a 27‐Year‐Old Man. Abstract published at Hospital Medicine 2007, May 23-25, Dallas, Texas Abstract 136. Journal of Hospital Medicine. 2007; 2 (suppl 2). https://www.shmabstracts.com/abstract/tumefactive-multiple-sclerosis-presenting-as-ringenhancing-lesions-on-computerized-tomography-of-the-brain-in-a-27yearold-man/. Accessed July 22, 2019.

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