Manifestation of multiple sclerosis with paranoidhallucinatory psychosis

Alemtuzumab significantly improves posterior fossa syndrome presented as a relapse of multiple sclerosis

BACKGROUND

Posterior fossa syndrome (PFS) is a rare manifestation of ponto-mesencephalic lesions frequently reported in post-surgical pediatric tumors, rarely described as a consequence of vascular, infective or inflammatory lesions.

OBJECTIVE

The aim of this article is to report the clinical and neuroradiological characteristics of a patient with an acute PFS presentation as a relapse in relapsing-remitting MS, significantly responsive to Alemtuzumab treatment.

CASE REPORT

24-year-old patient affected by multiple sclerosis developed motor-cognitive and behavioral syndrome related to an extensive ponto-mesencephalic lesion under Fingolimod treatment.

CONCLUSION

Our case highlights the significant and rapid effect of Alemtuzumab therapy on both cognitive and motor symptoms occurring during a MS relapse with atypical neuroradiological localization.

Neuropsychiatric syndromes of multiple sclerosis

Neuropsychiatric signs and symptoms occur frequently in individuals with multiple sclerosis (MS), either as the initial presenting complaint prior to a definitive neurological diagnosis or more commonly with disease progression. However, the pathogenesis of these comorbid conditions remains unclear and it remains difficult to accurately elucidate if neuropsychiatric symptoms or conditions are indicators of MS illness severity. Furthermore, both the disease process and the treatments of MS can adversely impact an individual's mental health. In this review, we discuss the common neuropsychiatric syndromes that occur in MS and describe the clinical symptoms, aetiology, neuroimaging findings and management strategies for these conditions.

Charles Bonnet syndrome

BACKGROUND

Charles Bonnet syndrome (CBS) involves nonthreatening hallucinations in patients who have no neurological and no psychological abnormalities but with significant visual impairment secondary to ocular disease, such as macular degeneration and diabetic retinopathy. Because of the fear of a mental illness being diagnosed, patients are often reluctant to discuss these hallucinations.

CASE REPORTS

Three cases are presented of patients who experienced CBS caused by decreased vision. Each patient had decreased vision and related visual hallucinations that were consistent with CBS. The first patient underwent magnetic resonance imaging and psychological evaluation, which confirmed our suspicion. The other 2 patents were not willing to undergo further testing, so our diagnosis is presumptive.

CONCLUSION

Management for these hallucinations includes treatment of the actual ocular disease as well as optimizing vision for the patient using appropriate low vision devices. As the population continues to age, more patients will be seen with reduced vision caused by a myriad of ocular diseases, increasing the likelihood that more patients may present with CBS in the future. It is therefore prudent to become familiar with the syndrome so primary care optometrists can properly identify CBS and help their patients deal with it.

Diffusion tensor imaging, structural connectivity, and schizophrenia

A fundamental tenet of the "disconnectivity" theories of schizophrenia is that the disorder is ultimately caused by abnormal communication between spatially disparate brain structures. Given that the white matter fasciculi represent the primary infrastructure for long distance communication in the brain, abnormalities in these fiber bundles have been implicated in the etiology of schizophrenia. Diffusion tensor imaging (DTI) is a magnetic resonance imaging (MRI) technique that enables the visualization of white matter macrostructure in vivo, and which has provided unprecedented insight into the existence and nature of white matter abnormalities in schizophrenia. The paper begins with an overview of DTI and more commonly used diffusion metrics and moves on to a brief review of the schizophrenia literature. The functional implications of white matter abnormalities are considered, particularly with respect to myelin's role in modulating the transmission velocity of neural discharges. The paper concludes with a speculative hypothesis about the relationship between gray and white matter abnormalities associated with schizophrenia.

Use of aripiprazole in a patient with multiple sclerosis presenting with paranoid psychosis

Multiple sclerosis (MS) is an autoimmune neurodegenerative disorder of the central nervous system (CNS). A significant percentage of MS patients will develop neuropsychiatric symptoms during their lifetime; affective symptoms are most common, but psychosis is reported in approximately 1% of patients. Atypical antipsychotics are commonly prescribed for treatment of psychotic symptoms and a recent case report demonstrated the benefit of oral aripiprazole 10 mg in treating paranoid-hallucinatory psychosis in a patient with MS. We report on a 46-year-old African-American female diagnosed with MS who was admitted with delusional and paranoid behavior. She had no history of mental illness and had a negative urine drug screen on admission. Following 3 days of treatment with oral aripiprazole, the patient became more cooperative with hospital staff, took her prescribed medications, and demonstrated a reduction in paranoid behavior and delusional thinking. She was discharged on oral aripiprazole 10 mg twice daily. This case report suggests the benefit of aripiprazole for psychotic symptoms in MS. Further study of aripiprazole's efficacy is needed to confirm these findings.

Psychotic features associated with multiple sclerosis

Although once considered rare, several more recent investigations have been published describing psychotic features in multiple sclerosis (MS). The association between the two conditions, however, remains unclear. Large-scale hospital-based, epidemiological and case studies have suggested a relationship between psychosis and MS through demonstrating their higher than chance co-occurrence, their temporal relationship, and their association with particular structural abnormalities in the brain (i.e., periventricular white matter and temporal demyelination). The etiology of psychosis in MS has also not been explained adequately. Regional demyelination and the use of corticosteroids have been implicated, yet their mechanisms of action have not been elucidated. The present review addresses what is known at this point in time regarding the occurrence of psychosis in the context of MS, the data regarding possible etiological factors, and the implications of these data and suggestions regarding diagnosis and treatment. Future research should explore the underlying pathophysiology of psychosis and multiple sclerosis to further our understanding of the central nervous system disease process. This research could help determine the features which would guide clinicians in identifying patients at risk of developing psychosis in the context of MS, as well as propose the optimal pharmacological intervention.

Psychiatric disorders in multiple sclerosis patients

Multiple sclerosis (MS) is a demyelinating disease showing variable clinical presentation. Optic neuritis is the most common symptom, followed by motor and sensitive manifestations. It is known that this disease may be related to several psychiatric disorders, especially depression. In this study we will discribe 5 cases of MS patients harboring psychiatric disorder related or unchained by the disease itself.

Case report: "Purely" psychiatric presentation of multiple sclerosis in an adolescent boy

We present the case of a 14-year-old Hispanic boy with a 6-month history of a psychotic disorder necessitating several hospitalizations who was incidentally found to have multiple sclerosis with no physical findings. Neuropsychological assessment has revealed impairments in word-finding, bilateral fine motor skills, and attention. Imaging and laboratory studies have supported the diagnosis of multiple sclerosis. Steroid and immunomodulating therapy has not significantly affected psychiatric symptoms. He has had poor response to psychotropic medications as well. We discuss the implications of multiple sclerosis as the cause of this patient's psychiatric illness.