Difficult dx

[jbd3dmd]

I'm a 50 yo male, previously in excellent health. I had episodes of dizziness and bp spikes (to 220/150) that lead to a primary care visit. past hx of anaphalaxis (food)precludes beat blockers and now bp typically 140/80 without meds. MRI revealed numerous white lesions so need to r/o Lymes, MS, etc. All labs have been wnl (no oligoclonal banding,no evidence of lymes in blood or csf, visual evoked potentials wnl., etc. 2nd MRI 4 months later revealed changes and corpus collosum involvement. Spinal MRI wnl. Only symptoms are very symmetrical areas of reduced sensation (not truly numb) on both feet near the base of the middle toe and occasional warm slight tingling in my legs. My neurologist (MD/PhD) is stumped. I have an MS MRI but no other evidence of the disease. No changes in peripheral neuropathy in 6 months at all. I'm going to a MS sub-specialist in August for a consult. I'm on Avonex in the mean time. No family hx of MS although mother has narcolepsy. Can you add anything to the differential? Any help very much appreciated.

[jbd3dmd]

Thanks a lot. I'll second the comments made by Cindy and Phil and add that your tendency to answer all questions like you are talking to a peer is also very much appreciated. Even though the 'news' may be unwelcome, we have an excellent 'messenger'. I'll post more info after my consult. One other ? in the meantime, though. Cerebral vasculitis I believe is treated with high doses of steroids for up to a year. Does it have a similar MRI signature? What are the signs/symptoms of that illness and is an angiogram an absolute necessity for the dx? I'm a little wary of that as my dad stroked while his carotid was being opened up and spent the last 7 years of his life as an invalid. Thanks again..

[CCF-Neuro-M.D.-RPS]

Dear JBD3dmd:

I am sorry that you have signs and symptoms that are so worrisome.  Although it makes you crazy with worry not knowing what is going on, the normal labs are actually a good sign.  Alot depends on where the white matter lesions are and how did they elucidate if the second MRI actually had new lesions?  The worrisome finding is the corpus callosum areas.  If these are indeed demyelinating areas then there are actually few things that can do it, MS, a rare disease in italian men who drink red wine (doesn't sound like you), glioblastoma (although no well known we have seen several cases-but this is not you as you would be already diagnosed), oligodendroglioma (again this would be more definitive on MRI) and lymphoma (again not you).  Now, one needs to know who read the film-as sometimes things are mistakenly called.  Hypertension can cause small vascular events and these can give spots on the MRI.  This we know you have, so some of the MRI changes might be do to this.  However, the corpus callosum changes signal MS as very high on the diagnosis list.  If true, then MS is on the top of the list.  I truely hope that the corpus lesion is artifact or a misreading and the changes are due to hypertension.   Hang in there.

Sincerely,

CCF Neuro MD