Bithalamic Inflammation in Relapsing-Remitting Multiple Sclerosis

A 27-year-old gentleman recently diagnosed with relapsing-remitting multiple sclerosis, awaiting insurance authorization for disease-modifying therapy initiation, presented with 4 days of numbness, paresthesias, and mild left hemibody weakness, followed by dysphagia and stuttering. Examination demonstrated normal mental status, slowed and hesitant speech, mild left nasolabial flattening, decreased light touch and temperature over the left hemibody, and mild left hemiparesis. Magnetic resonance imaging (MRI) revealed prominent T2/FLAIR lesions of the bilateral thalami (Figure 1A), plus multiple new white matter lesions, without evidence of deep cerebral venous thrombosis. Due to concern that the thalamic lesions were atypical of demyelinating disease, further evaluation was performed. Cerebrospinal fluid showed 3 × 106 WBC/L, protein 31 mg/dL, and glucose 65 mg/dL Bacterial culture of the CSF revealed no organisms. Cytology and flow cytometry of the CSF were normal. Immunoglobulin index was 0.5 and there were greater than 5 unique oligoclonal bands in the CSF. Computed tomography of the chest with contrast was also normal. He received high-dose steroids and transitioned to fingolimod as an outpatient. Repeat MRI 3 months later showed near resolution of the bithalamic lesions (Figure 1B)