Cognitive impairment and neuropsychiatric manifestations at the onset of multiple sclerosis: case report

Background: Multiple sclerosis (MS) is a demyelinating disease of the central nervous system that mainly affects young adults and leads to a wide range of signs and symptoms, including physical, cognitive and psychiatric manifestations. The cognitive manifestations are slow processing speed, reduced memory and attention performance. Psychiatric disorders include depression, anxiety, bipolar disorder, and psychosis. The first manifestations of the disease are various and sometimes atypical, they can also mimic any other condition. Material and methods: Case report of early atypical manifestations of MS. Results: A 26-year-old man presented with diplopia, cognitive decline (inattention and episodes of memory loss) and psychiatric impairment, rapidly progressing during the last 6 months. Dysphoria and anxiety appeared after the cognitive decline. Initially the patient was considered to suffer from a psychiatric disorder, but treatment with anticonvulsants (valproic acid) didn’t produce any effect. Neurological examination revealed generalized hyperreflexia, a left pyramidal syndrome and diplopia. Brain MRI demonstrated multiple contrast enhanced ring like lesions (~ N10) in the periventricular and juxtacortical white matter, cerebellum, brainstem, genu of the corpus callosum and cervical spinal cord. Cerebrospinal fluid evaluation demonstrated a presence of specific oligoclonal bands. The treatment with methylprednisolone 1g/day for 5 days suppressed the psychiatric and cognitive manifestations. The patient was referred to disease modifying treatment. Conclusions: Recognition of early atypical manifestations of MS such as cognitive impairment and psychiatric disorders is important to avoid diagnostic errors and inappropriate, potentially harmful treatments