Objective:

N/A

Background:

Multiple sclerosis (MS) is a chronic, inflammatory, demyelinating autoimmune disease that predominantly affects the central nervous system. First-line treatment of acute MS flares include immunosuppressive therapies such as high dose corticosteroids, and in severe cases, plasmapheresis. A potential complication of immunosuppressive therapy is the reactivation of latent viral infections. 

Design/Methods:

N/A

Results:

A 50-year-old male with history of multiple sclerosis was admitted for lethargy and confusion. He became comatose the day following admission and was intubated. Lumbar puncture was notable for WBC of 146cells/uL, protein 83mg/dL and glucose 86mg/dL. Oligoclonal bands were positive at 6 and CSF IgG was elevated to 15.3mg/dL. A CSF meningitis panel including PCR for HSV-1 and HSV-2 was negative. MRI of the brain and whole spine with contrast revealed multiple areas of edema and demyelination within the medulla, cervical and thoracic cord. 1g daily methylprednisolone was started with a 5 day course of plasmapheresis. His mental status gradually improved to awake, alert and tracking with eyes. Following this improvement, he gradually deteriorated back to a comatose state over the course of three days. He became febrile to 39.1°C. A repeat lumbar puncture was obtained and notable for protein 113mg/dL, WBC 37 cells/uL and positive PCR for HSV-2. He was started on acyclovir for HSV-2 meningoencephalitis and had rapid improvement to awake, alert, holding conversation and following commands the following week. He was ultimately discharged to a rehabilitation facility.

Conclusions:

Reactivation of viral infection should be considered in patients with MS who experience improvement with immunosuppressive therapy followed by worsening of mental status. The threshold to repeat a lumbar puncture should be low when a patient's clinical exam suddenly deteriorates.