567729
letter2015
MSJ0010.1177/1352458514567729Multiple Sclerosis JournalX Wu et al.
MULTIPLE SCLEROSIS MSJ JOURNAL
Letter
Multiphasic acute disseminated encephalomyelitis associated with atypical rubella virus infection Date received: 27 October 2014; accepted: 17 December 2014 Dear Sir, We read the case report by Shinoda and colleagues1 with great interest. They diagnosed multiphasic acute disseminated encephalomyelitis (ADEM) associated with atypical rubella virus infection in a 17-year-old male based on the clinical manifestations, laboratory investigations, the results of sequential magnetic resonance imaging (MRI) and the pathological findings.1 However, the diagnosis of relapsing–remitting multiple sclerosis (RRMS) could not be ruled out based on the current clinical data. RRMS and ADEM are both immune-mediated and relapsing disorders characterized by the inflammatory demyelination of the central nervous system, although they are considered to be clinically heterogeneous.2 The therapeutic strategy of the RRMS and multiphasic ADEM might be different because it had been reported that interferon beta treatment, the first-line option in patients with RRMS, might exacerbate multiphasic ADEM.3 Taken together, the differential diagnosis between multiphasic ADEM and RRMS is of great importance. RRMS, accounting for 85% of all MS cases, is characterized by at least one clinical attack resulting from demyelination (relapsing phase) followed by complete or partial recovery (remitting phase). According to the clinical features and MRI findings, ADEM could be classified as monophasic, multiphasic or recurrent form.4 However, the multiphasic or recurrent form of ADEM has been poorly defined thus far and is usually difficult to differentiate with RRMS, especially during the first episode, because of the similar clinical and pathological presentations.2 The clinical manifestations of multiphasic ADEM usually include predemyelinating infections, polysymptomatic manifestations, seizures and encephalopathy.5 The peripheral nerve involvement and the MRI lesions including thalami, basal ganglia and cortices are common in ADEM.6,7 In addition, the oligoclonal bands (OCBs) in the cerebrospinal fluid
(CSF) and visual evoked potential (VEP) (both common in RRMS) might help the differentiation between multiphasic ADEM and RRMS.6,7 Recently it was found that the serum autoantibodies to myelin peptides might be useful for distinguishing MS from ADEM.8 However, the above features were nonspecific and none could become a distinct hallmark.
Multiple Sclerosis Journal 1–2 DOI: 10.1177/ 1352458514567729 © The Author(s), 2015. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav
In the case report, the differential diagnosis between RRMS and multiphasic ADEM was difficult. Without the results of serum autoantibodies to myelin peptides, VEP and peripheral nerve involvement in the case report, the mentioned sequential clinical manifestations, laboratory investigations and the pathological findings were all nonspecific to the distinction. As to the sequential MRI findings, these sequential MRI lesions, predominantly in the white matter, separated in time and space, also met the criteria of RRMS. In summary, due to the overlapping clinical evidence and inadequate data, the diagnosis of RRMS in the patient in the case report should be taken into consideration. Conflict of interest The authors declare that there is no conflict of interest. Funding This work was supported by Young Scholars Program of Norman Bethune Health Science Center of Jilin University (grant no. 2013205035), Young Scholars Program of the First Hospital of Jilin University (grant no. JDYY42013003), the Scientific Research Foundation for the Returned Overseas Chinese Scholars, State Education Ministry, and the National Natural Science Foundation of China (grant no. 81241147).
References 1. Shinoda K, Asahara H, Uehara T, et al. Multiphasic acute disseminated encephalomyelitis associated with atypical rubella virus infection. Mult Scler. Epub ahead of print 22 May 2014. 2. Brinar VV and Poser CM. Disseminated encephalomyelitis in adults. Clin Neurol Neurosurg 2008; 110: 913–918. 3. Chen S, Wu A, Zhang B, et al. A case of exacerbated multiphasic disseminated encephalomyelitis after interferon beta treatment. J Neurol Sci 2013; 325: 176–179.
http://msj.sagepub.com 1
Downloaded from msj.sagepub.com at GEORGIAN COURT UNIV on February 19, 2015
Multiple Sclerosis Journal 4. Krupp LB, Banwell B and Tenembaum S; International Pediatric MS Study Group. Consensus definitions proposed for pediatric multiple sclerosis and related disorders. Neurology 2007; 68: S7–S12.
8. Van Haren K, Tomooka BH, Kidd BA, et al. Serum autoantibodies to myelin peptides distinguish acute disseminated encephalomyelitis from relapsing–remitting multiple sclerosis. Mult Scler 2013; 19: 1726–1733.
5. Dale RC, de Sousa C, Chong WK, et al. Acute disseminated encephalomyelitis, multiphasic disseminated encephalomyelitis and multiple sclerosis in children. Brain 2000; 123: 2407–2422.
Xiujuan Wu, Juan Wang, Kangding Liu and Hongliang Zhang Neuroscience Center, Department of Neurology, the First Hospital of Jilin University, Jilin University, Changchun, China
6. Tavazzi E, Ravaglia S, Franciotta D, et al. Differential diagnosis between acute disseminated encephalomyelitis and multiple sclerosis during the first episode. Arch Neurol 2008; 65: 676–677. Visit SAGE journals online http://msj.sagepub.com
SAGE journals
7. Lee YJ. Acute disseminated encephalomyelitis in children: Differential diagnosis from multiple sclerosis on the basis of clinical course. Korean J Pediatr 2011; 54: 234–240.
Correspondence to: Hongliang Zhang Neuroscience Center, Department of Neurology, the First Hospital of Jilin University, Xinmin Street 71#, 130021, Changchun, China. [email protected]
2 http://msj.sagepub.com
Downloaded from msj.sagepub.com at GEORGIAN COURT UNIV on February 19, 2015
letter2015
MSJ0010.1177/1352458514567729Multiple Sclerosis JournalX Wu et al.
MULTIPLE SCLEROSIS MSJ JOURNAL
Letter
Multiphasic acute disseminated encephalomyelitis associated with atypical rubella virus infection Date received: 27 October 2014; accepted: 17 December 2014 Dear Sir, We read the case report by Shinoda and colleagues1 with great interest. They diagnosed multiphasic acute disseminated encephalomyelitis (ADEM) associated with atypical rubella virus infection in a 17-year-old male based on the clinical manifestations, laboratory investigations, the results of sequential magnetic resonance imaging (MRI) and the pathological findings.1 However, the diagnosis of relapsing–remitting multiple sclerosis (RRMS) could not be ruled out based on the current clinical data. RRMS and ADEM are both immune-mediated and relapsing disorders characterized by the inflammatory demyelination of the central nervous system, although they are considered to be clinically heterogeneous.2 The therapeutic strategy of the RRMS and multiphasic ADEM might be different because it had been reported that interferon beta treatment, the first-line option in patients with RRMS, might exacerbate multiphasic ADEM.3 Taken together, the differential diagnosis between multiphasic ADEM and RRMS is of great importance. RRMS, accounting for 85% of all MS cases, is characterized by at least one clinical attack resulting from demyelination (relapsing phase) followed by complete or partial recovery (remitting phase). According to the clinical features and MRI findings, ADEM could be classified as monophasic, multiphasic or recurrent form.4 However, the multiphasic or recurrent form of ADEM has been poorly defined thus far and is usually difficult to differentiate with RRMS, especially during the first episode, because of the similar clinical and pathological presentations.2 The clinical manifestations of multiphasic ADEM usually include predemyelinating infections, polysymptomatic manifestations, seizures and encephalopathy.5 The peripheral nerve involvement and the MRI lesions including thalami, basal ganglia and cortices are common in ADEM.6,7 In addition, the oligoclonal bands (OCBs) in the cerebrospinal fluid
(CSF) and visual evoked potential (VEP) (both common in RRMS) might help the differentiation between multiphasic ADEM and RRMS.6,7 Recently it was found that the serum autoantibodies to myelin peptides might be useful for distinguishing MS from ADEM.8 However, the above features were nonspecific and none could become a distinct hallmark.
Multiple Sclerosis Journal 1–2 DOI: 10.1177/ 1352458514567729 © The Author(s), 2015. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav
In the case report, the differential diagnosis between RRMS and multiphasic ADEM was difficult. Without the results of serum autoantibodies to myelin peptides, VEP and peripheral nerve involvement in the case report, the mentioned sequential clinical manifestations, laboratory investigations and the pathological findings were all nonspecific to the distinction. As to the sequential MRI findings, these sequential MRI lesions, predominantly in the white matter, separated in time and space, also met the criteria of RRMS. In summary, due to the overlapping clinical evidence and inadequate data, the diagnosis of RRMS in the patient in the case report should be taken into consideration. Conflict of interest The authors declare that there is no conflict of interest. Funding This work was supported by Young Scholars Program of Norman Bethune Health Science Center of Jilin University (grant no. 2013205035), Young Scholars Program of the First Hospital of Jilin University (grant no. JDYY42013003), the Scientific Research Foundation for the Returned Overseas Chinese Scholars, State Education Ministry, and the National Natural Science Foundation of China (grant no. 81241147).
References 1. Shinoda K, Asahara H, Uehara T, et al. Multiphasic acute disseminated encephalomyelitis associated with atypical rubella virus infection. Mult Scler. Epub ahead of print 22 May 2014. 2. Brinar VV and Poser CM. Disseminated encephalomyelitis in adults. Clin Neurol Neurosurg 2008; 110: 913–918. 3. Chen S, Wu A, Zhang B, et al. A case of exacerbated multiphasic disseminated encephalomyelitis after interferon beta treatment. J Neurol Sci 2013; 325: 176–179.
http://msj.sagepub.com 1
Downloaded from msj.sagepub.com at GEORGIAN COURT UNIV on February 19, 2015
Multiple Sclerosis Journal 4. Krupp LB, Banwell B and Tenembaum S; International Pediatric MS Study Group. Consensus definitions proposed for pediatric multiple sclerosis and related disorders. Neurology 2007; 68: S7–S12.
8. Van Haren K, Tomooka BH, Kidd BA, et al. Serum autoantibodies to myelin peptides distinguish acute disseminated encephalomyelitis from relapsing–remitting multiple sclerosis. Mult Scler 2013; 19: 1726–1733.
5. Dale RC, de Sousa C, Chong WK, et al. Acute disseminated encephalomyelitis, multiphasic disseminated encephalomyelitis and multiple sclerosis in children. Brain 2000; 123: 2407–2422.
Xiujuan Wu, Juan Wang, Kangding Liu and Hongliang Zhang Neuroscience Center, Department of Neurology, the First Hospital of Jilin University, Jilin University, Changchun, China
6. Tavazzi E, Ravaglia S, Franciotta D, et al. Differential diagnosis between acute disseminated encephalomyelitis and multiple sclerosis during the first episode. Arch Neurol 2008; 65: 676–677. Visit SAGE journals online http://msj.sagepub.com
SAGE journals
7. Lee YJ. Acute disseminated encephalomyelitis in children: Differential diagnosis from multiple sclerosis on the basis of clinical course. Korean J Pediatr 2011; 54: 234–240.
Correspondence to: Hongliang Zhang Neuroscience Center, Department of Neurology, the First Hospital of Jilin University, Xinmin Street 71#, 130021, Changchun, China. [email protected]
2 http://msj.sagepub.com
Downloaded from msj.sagepub.com at GEORGIAN COURT UNIV on February 19, 2015
