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Multiple sclerosis, case 1

 

Clinical history
This 60-year-old male was admitted with rapidly progressive gait impairment, due to paresis of the right leg. Previous clinical history was noncontributory. No urinary disturbances were noted.

Neurological examination
Distal paresis (3/5) of the right leg with hyporeflexia and a right pyramidal syndrome. An emergency CT was considered normal.

MRI
MRI of the lower thoracic spine included sagittal T1 and T2 images which were normal and not shown here. Only Gadolinium enhanced images showed a small oval enhancing lesion.
Images 1 - 2: Sagittal and axial Gd T1WI. At this time, differential diagnosis included a small primary spinal cord tumor, metastasis, an infectious lesion, and MS. Brain MRI was performed and helped to provide the final diagnosis of MS, as multiple highly suggestive lesions were visible in the brain. This diagnosis was confirmed by CSF examination.
Image 3: Axial PD and T2WI image.

Follow-up clinical course
Three months after high dose corticosteroid therapy the paresis of the right leg disappeared.

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Fig. 1

Multiple sclerosis, case 1, Fig. 1
Multiple sclerosis, case 1, Fig. 2
Multiple sclerosis, case 1, Fig. 3