Medical Report

MEDICAL REPORT

Bianco Marco, born 26/04/80

MB is a 33-year-old previously healthy man admitted to our hospital during late November 2012 because of rapidly progressive neurological symptoms (memory loss, change in the behavior) that prompted to an unconscious status when he was sent to our observation. His past medical history was unremarkable until 20 days before our observation when headache and asthenia developed followed by progressive memory loss and hallucination during the next week.

At admission MB was collaborating and reported severe working memory loss. A lumbar puncture was performed at admission and revealed high CSF protein 1620 mg/L, less than 10 cells/mL, and Glucose 83 mg/dl. An MRI showed multiple lesion of the white matter consistent with the diagnosis of Acute Disseminated Encephalomyelitis with slight gadolinium enhancement within the corpus callosum. A wide search of antibodies against common virus involved in such cases revealed the presence of CMV-IgM (his 2-year son was subsequently find to  have CMV-DNA at urine analysis). No evidence was reported by an extensive microbiological evaluation of the CSF including cultures, and search of DNA by PCR of HSV, EBV, HHV6 and of RNA by Enterovirus. No evidence was obtained by general laboratory analysis.

After admission, steroids and acyclovir were administered during a 5-day period before laboratory evidences where available. During this period symptoms worsened and the patients was progressively unconscious and agitated, left-sided hemiparesis developed. Pulse steroid therapy was administered over a 3-day course  (Gancyclovir was associated because of threatened CMV reactivation), symptoms only slightly improved after a 10-day period high dose immunoglobulin were administered with a low-dose steroid therapy. After Immunoglobulin general symptoms improved and the patient returned home. At the discharge from our hospital, there were memory loss, meddle weakness (left>right) and MOCA test score was 19/30 with loss in memory and visu-spatial performance. An MRI of the brain confirmed disseminate white matter lesions without gadolinium enhancement.

During the next 3 months conditions improved and BM returned slowly to his normal working activity until in late march of this year reduction of his left auditory performance was reported. For this reason a new MRI was performed but no new significant finding was reported. The patient was sent home with indication to steroid therapy that was only partially followed, without any significant improvement.

Two weeks after this observation symptoms gradually worsened and an unconscious state developed. The patient was again admitted to our hospital and new MRI and lumbar puncture were performed revealing an increase of CSF protein without new lesion of the brain. Immunoglobulin therapy was started and symptoms improved rapidly. Fifteen days after admission a peripheral palsy of left-sided VII cranial nerve developed and steroids and acyclovir were administered with improvement. A lumbar puncture revealed a decrease without normalization of CSF protein without any evidence of viral or bacterial replication by an extensive evaluation. Thirty days after admission symptoms worsened again until to reach an unconscious state within a 3-day period and low grade fever was reported, a repeat EEG at that time showed mixed theta-delta activity, but ruled out non-convulsive status epilepticus, Immunoglobulin during a 5-day course were again administered and an improvement of neurological findings was observed. Gancyclovir was added on suspicious of CMV reactivation.

His last physical examination shows an improvement of general condition and persistence of behavioral symptoms, laboratory examination does not show abnormalities. 

20/05/2013 Transferred to the Policlinico the new diagnosis is "MULTIPLE SCLEROSIS malignant" which has 4 trips:
• High protein in serum,• the absence of bands in oligloconali Liquor,• lesions not visible with the contrast
• negative responses to steroid treatment
21/05/2013 analysis of the serum was positive for anti-JCV
26/05/2013 Worsening, is no longer able to feed only, is fed by gavage.
27/05/2013 Tysabri is administered