Presentation
Three week history of fevers, ataxia and difficulty passing urine
Patient Data
There is subtle increase in signal on FLAIR sequences along the sulcal margins, there is also increased signal noted in the thalami bilaterally. Additionally the periventricular white matter around the 4th ventricle shows some subtle increase in signal. However the subtle increase in signal on FLAIR sequences is non-specific.
The patient was found to have raised inflammatory markers, ESR 41 cm/hr and CRP 56 mg/L.
CSF cytology: The CSF was highly cellular consisting of numerous lymphoid cells and occasional neutrophils.
Working diagnosis: aseptic meningitis
This study demonstrates extensive FLAIR hyperintensity in the deep white matter, now confluent, which is more prominent than previously, which may be secondary to the encephalitis. Of note is the confluent smooth signal change in the ependymal regions.
CSF and serum were found to have an identical oligoclonal IgG banding. CSF was also sent for cytopathology which showed no cytological evidence of malignancy.
Working diagnosis: encephalitis
There are persistent extensive FLAIR hyperintensities in the deep white matter and pericallosal white matter which are similar to the previous examination.
The stable white matter changes could be due to resolving encephalitis. The differential includes demyelination/ADEM.
The serum was sent for flow cytometry for anti-MOG antibodies and it was found to be positive on three out of three assays.
Diagnosis: anti-MOG encephalomyelitis
Case Discussion
Anti-MOG associated encephalomyelitis falls under the umbrella of neuromyelitis optica spectrum disorder (NMOSD) which is the target of rapidly developing research.
Despite a predominance of anti-MOG encephalomyelitis in children and young adults 1, this case demonstrates occurrence in an older individual, which caused a diagnostic dilemma.
This case also demonstrates the benefit of the 3 tesla scanner in the diagnosis of this disease, which was capable of demonstrating multiple imaging features that are useful in distinguishing this entity from other demyelinating diseases (e.g. MS):
- large, confluent lesions
- smooth confluent periependymal involvement
- more extensive involvement of the corpus callosum (especially its ependymal surface)
- diencephalic involvement
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