Presentation
This patient presented with flu-like symptoms, progressing to drowsiness, diplopia, vertigo/ataxia, and right-sided facial hemiparesthesia within a week. There was no history of head injury or toxic exposure, and a brain CT scan was normal.
Patient Data
MRI reveals a focal abnormal signal in the pons' right dorsal aspect, traversing the pontine tract of the trigeminal nerve on the same side. The affected area demonstrates a faint low signal on T1-weighted sequences and a bright signal on T2/FLAIR sequences. No evidence of blooming, diffusion restriction, or enhancement following gadolinium administration exists. Additionally, no mass effect or perifocal edema is present.
Impression: The clinical presentation and MRI findings are initially consistent with the Fisher-Bickerstaff spectrum.
Electromyoneurography
The patient underwent an EMNG examination, demonstrating afferent dysfunction of the right hemiface sensory pathways. This finding may correspond to a partial lesion of the trigeminal nerve or in the primary sensory nucleus of this nerve.
Diagnosis
Considering the clinical picture of acute brainstem dysfunction after an infectious flu syndrome, supported by the neurophysiological studies and brain MRI appearance, the primary consideration was the diagnosis of Bickerstaff encephalitis.
Case Discussion
Bickerstaff encephalitis is an autoimmune condition characterized by acute brainstem dysfunction 1-6. It typically occurs a few days after an infection or vaccination and follows a self-limiting course with a favorable prognosis in most cases 1-6.
Based on clinical data, the present case illustrates probable Bickerstaff encephalitis with the contribution of neurophysiological studies and brain MRI appearance. The patient experienced a progressive improvement in neurological symptoms following a natural recovery trajectory, with discharge from the hospital after the third week.
Case courtesy:
Murilo Pessoa, MD – Radiology resident, PGY-3, Department of Radiology
Maria Eduarda Calado, MD - Pediatrics resident, PGY-2, Department of Pediatrics
Fernanda Serpa, MD – Pediatrician, Department of Pediatrics
Luziany Carvalho Araújo, MD - Neuroradiologist, Department of Radiology
Antonio Rodrigues de Aguiar Neto, MD - Radiologist, Department of Radiology
Hospital da Restauração – Recife, PE – Brazil