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INS;Bucy Syndrome in a multiple sclerosis patient
Abstracts / Journal of the Neurological Sciences 333 (2013) e358–e421
impaired mobility and lower quality of life. The impact of spasticity on healthcare utilization (HCU) is poorly understood. Objective: Assess association of spasticity and HCU among North American Research Committee on Multiple Sclerosis (NARCOMS) registry participants. Patients and methods: NARCOMS maintains a self-report database of MS patients who volunteer health-related information through online or paper questionnaires at enrollment and semi-annually thereafter. Among 5172 individuals who completed surveys in 2005 and 2011, we evaluated the association of HCU with spasticity reported using the 5-point Performance Scales spasticity subscale (PSss). Results: Responders were predominantly female (76.2%) and white (96.2%). In 2005 mean (SD) age was 52 (9.8) years, disease duration 13.7 (9.1) years, and 50.8% could walk unassisted. 18.8% reported no spasticity, 36.2% minimal, 17.5% mild, 15.7% moderate, 9.9% severe and 1.9% total. In the prior 6 months, 653 (13.2%) reported an ER visit while 358 (7.1%) reported hospitalization. Frequencies for both increased with spasticity severity (p b 0.001 for linear trend). Over 6 years, PSss improved or remained stable in 74.9% and worsened in 25.9%. Versus participants whose PSss score worsened, those with improved spasticity were less likely to report an ER visit (OR 0.83; 95%CI: 0.67-1.03) or hospitalization (OR 0.76; 95%CI: 0.59–0.99) even after accounting for disability and sociodemographic factors. Conclusion: More severe spasticity is associated with greater HCU, emphasizing the adverse impact of spasticity and suggesting that effective treatment of spasticity might reduce HCU. doi:10.1016/j.jns.2013.07.1371
Abstract — WCN 2013 No: 2462 Topic: 6 — MS & Demyelinating Diseases Absence of delayed facilitation and post-exercise facilitation at early stage of multiple sclerosis: Evidence of altered cortical plasticity? S. Simeoni, I. Pittaro-Cadore, V. Russo, A. Fontana, G.L. Gigli, A. Scalise. University of Udine Medical School, Neurology, Udine, Italy Background: By means of transcranial magnetic stimulation (TMS) multiple sclerosis (MS) has been studied. Disabilities correlate with alterations of TMS parameters such as prolonged central motor conduction time, prolonged motor evoked potential (MEP) latencies and increased motor threshold (MT). TMS has also been used to explore movement-related cortical plasticity. Objective: To compare cortical excitability in patients at early stage of MS versus healthy controls. Material and methods: In each subject TMS of non-dominant hemisphere was used to define MEP amplitude and motor threshold (MT). Then subjects performed 3 blocks (30-s, 60-s, and 90-s duration) of a bimanual motor task (exercise condition). Amplitudes of MEPs elicited immediately after each block, and then after a 15-minute rest period were compared with baseline to evaluate the presence of postexercise facilitation and delayed facilitation. Patients were not receiving any therapy and their Expanded Disability Status Scale score was between 1 and 2.5. Results: MT resulted significantly higher in patients compared to controls. Compared with baseline, controls had larger MEP amplitudes after 30 and 60 s of exercise (post-exercise facilitation) and also after the rest period (delayed facilitation). In contrast, MEP amplitudes in patients were not significantly different from baseline after any of the exercise conditions or following the rest period. Conclusion: Patients do not show the normal fluctuations of cortical excitability usually found after a bimanual finger motor task. These
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results suggest an alteration in the cortical plasticity. We speculate that in SM patients capability to recover from functional impairments caused by demyelination is compromised. doi:10.1016/j.jns.2013.07.1372
Abstract — WCN 2013 No: 2431 Topic: 6 — MS & Demyelinating Diseases Transorbital sonography in the hyperacute stage of optic neuritis: A bicentric case–control longitudinal, blind study P. Lochnera,b, R. Cantellob, L. Coppob, R. Nardonea, F. Tezzona, O. Raymkulovab, M. Leoneb, F. Brigoa,c. aDepartment of Neurology, General Hospital of Merano, Merano, Italy; bDepartment of Neurology, University A. Avogadro, Novara, Italy; cDepartment of Neurological, Neuropsychological, Morphological and Movement Sciences, Section of Clinical Neurology, University of Verona, Verona, Italy Background: Acute unilateral optic neuritis (ON) is known to be associated with an increased optic nerve sheath diameter (ONSD) as revealed by ultrasonographic investigations. However, there is no consensus in the literature on the diagnostic cut-off of ONSD. Objective: The goals of this study were to evaluate the accuracy/ sensibility of US in the diagnosis of acute ON, and to assess the association between ONSD threshold and ON. Patients and methods: A prospective blinded observational (case– control) bicentric study was performed. Seventeen consecutive patients with an acute non-compressive unilateral ON and onset of visual loss during the prior 10 days were included. We enrolled 20 healthy controls, matched by gender and age (±5 years). Two experienced vascular sonographers, blinded to the status of case or control and to the affected eye, performed the study using B mode US. ONSD was defined as a sign of nerve thickening, if the difference in nerve diameter of 0.3 mm or more, compared with the contralateral side or controls. Results: A significant ONSD increase on the affected compared to the health side, was found in all patients by both investigators (6.6 mm ± DS 0.85 versus 5.5 mms ± DS 0.66 p b .001). ONSD was normal in all controls (5.2 ± DS 0.62) mm and in all the non-affected eyes. Conclusions: Our findings suggest that transorbital sonography has a very high sensitivity in recognizing ON, similar to that of the visual evoked potentials. doi:10.1016/j.jns.2013.07.1373
Abstract — WCN 2013 No: 2460 Topic: 6 — MS & Demyelinating Diseases Klüver–Bucy Syndrome in a multiple sclerosis patient J.P.R.P.T. de Azevedoa, G.L. Vasquesa, C.D. Rochab, J.A.D.O. Júniorb, F.O. Gomesb, D.S. Diniza. aHospital das Clínicas, Universidade Federal de Goiás, Goiânia, Brazil; bFaculdade de Medicina, Universidade Federal de Goiás, Goiânia, Brazil Background: Multiple sclerosis (MS) can result in a complex net of neuropsychiatric symptoms. Klüver–Bucy Syndrome (KBS) is a rare complex behavioral syndrome. It's composed of psychic blindness, hyperorality, hypermetamorphosis, hypersexuality, disturbed dietary habits and placidity. It's widely related to temporal lobe lesions. Objective: Report the rare association between Multiple Sclerosis and Klüver–Bucy Syndrome. Material and methods: Case report.
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Abstracts / Journal of the Neurological Sciences 333 (2013) e358–e421
Results: A 32 year old woman diagnosed with MS by the age of 20 started a multiple incipient behavioral change. She was already in Secondary-Progressive phase of the disease. She presents with placidity, hyperorality, hypermetamorphosis and a complex disturbed dietary habit. She used to avoid non-sweet and usually add sugar or sweetener in all kinds of food. The MRI showed diffuse cerebral atrophy especially in the temporal lobes with poor inflammatory lesion in both of them. Topiramate and valproic acid were introduced and controlled well the sweet compulsion. Antipsychotics were tried in other behavioral symptoms. Conclusion: MS is a complex disease composed of both inflammatory and degenerative lesions. Neuropsychiatric symptoms can be related to both of them. There is a complex role of cognitive and special behavioral symptoms that compose MS spectrum, as KBS is shown in this abstract. doi:10.1016/j.jns.2013.07.1374
Abstract — WCN 2013 No: 2403 Topic: 6 — MS & Demyelinating Diseases Disability due to multiple sclerosis in Ukraine (10 year experience) V.A. Golyka, A.V. Ipatova, N.O. Gondulenkoa, A.P. Pivnykb, V.O. Pogorelovaa, N.E. Madyukovaa. aNeurology and Border States, Ukrainian State Institute of Medical and Social Problems of Disability, Dnepropetrovsk, Ukraine; bNeurorehabilitation, Ukrainian State Institute of Medical and Social Problems of Disability, Dnepropetrovsk, Ukraine Multiple sclerosis (MS) is one of the leading causes of permanent disability due to neurological conditions in young adults. Methods: 10 year (2003–2012) dynamics of MS prevalence and disability incidence rates for adult population (all per 100,000) was investigated. Disability grade (“invalidity” status) in Ukraine is set according to the Ministry of Health Order (no. 561, August 05, 2011) based on ICF (2001) principles. We compared MS prevalence (Ukraine Ministry of Health Statistics Dept.) and primary disability data structure due to MS and encephalomyelitis (IDC X codes G35, G36–37) in Ukrainian regions. Results: Global panukrainan MS prevalence was gradually increased (48.0–47.8–48.4–49.1–50.0–50.1–50.9–51.6–52.9–54.6) as well as MS disability incidence (2.4–2.4–2.6–2.7–2.6–2.5–2.6–2.9–3.0–3.1). We also discovered (the data are not collected in clinical statistics) the relatively high rates of disability incidence due to demyelinating encephalomyelitis (total rates 1.3–1.2–1.3–1.1–1.2–1.2–1.0–1.0–1.1– 0.9 for years 2003–2012 accordingly). Conclusions: Further disability data investigation should be performed for understanding the correctness of demyelinating encephalomyelitis diagnostics and protection from MS false negative diagnostics followed by improper expert-rehabilitation tactic. doi:10.1016/j.jns.2013.07.1375
Abstract — WCN 2013 No: 2321 Topic: 6 — MS & Demyelinating Diseases Magnitude and concurrence of anxiety and depression among attendees at tertiary care neurology unit in Oman with multiple sclerosis (MS) A. Al-Asmia, S. Al-Rawahib, Z. Al-Muqbalib, R. Nandhagopala, P.C. Jacobb, A. Gujjarb, S. Al-Adawib. aSultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman; bCollege of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
Background: Anxiety and depression are commonly reported by persons with multiple sclerosis (PwMS) but no data, to our knowledge, have emerged from Arab Islamic population. Objective: The study aims to investigate the prevalence of anxiety and depression among PwMS attending tertiary care hospital in Oman, Neurology Clinic, Sultan Qaboos University Hospital (SQUH). The characteristics such as socio-demographic and clinical variables were also explored. Methods: Consecutive and consenting PwMS were subjected to the following measures. The Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety (cut-point N 7) and depression (N7). Results: 54 patients with MS participated in our study and approximately 87% were on Interferon. The age range from 17 to 50 and the average age was 31.4 ± 8.84. In terms of gender, majority were female (males = 30% vs. 70% females). Approximately 50% of the attendees have acquired university or higher graduate education while 39% had completed secondary education. The rest acquired on the lower strata of education with one illiterate. The majority (69%) of attendees were married while 31% were single. Approximately 83% were employed, students or job-seekers. The majority of the patients had b4 in the EDSS. Prevalence of anxiety was 53%, depression 39% on HADS. Conclusions: Anxiety and depression are common in PwMS among the attendees of tertiary care in Oman. Such psychosocial variables have been largely unreported from non-western population. As these variables are strong indicators of burden of MS, concerted efforts are needed to address such psychosocial dysfunctions in the algorithms of care for PwMS. doi:10.1016/j.jns.2013.07.1376
Abstract — WCN 2013 No: 2394 Topic: 6 — MS & Demyelinating Diseases Acute disseminated encephalomyelitis (ADEM) – probably triggered by Borrelia burgdorferi infection – with fatal end I. Vargaa,b, D.I. Mineaa,b, R.M. Lupua, M. Mihaia, A. Dinua. aNeurology, Neuro-Psychiatry Hospital, Faculty of Medicine, Brasov, Romania; b Neurology, Transilvania University, Faculty of Medicine, Brasov, Romania Background: Acute disseminated encephalomyelitis (ADEM) is a nonvasculitic inflammatory demyelinating condition that usually occurs following a viral, bacterial or parasitic infection, or even spontaneously. Case presentation: We present a case of a patient of 48, who presented the onset of the actual disease with low-grade fever, fatigability, impaired gait and balance, symptoms debuted 2 months before he was admitted in our hospital. Neurological examination revealed bilateral cerebellar and pyramidal syndrome, thermo-algic hypoesthesia below T4 level and urinary incontinence. Cerebral MRI showed bilateral supraand infra-tentorial demyelinating lesions, some of it with gadolinium enhancement and cervico-thoracal MRI revealed extended thoracal myelitis; lumbar puncture showed CSF with pleocytosis and highlights the presence of IgG anti-Borrelia antibodies. We considered the infection with Borrelia burgdorferi as a possible “trigger” factor in apparition of ADEM. The evolution was initially with improvement of symptoms on treatment with cephalosporin and high doses of metilprednisolone. After 2 months, the patient presented sudden motor deficit in the inferior limbs with impairment of the gait and slurred speech. Cerebral and spinal MRI showed more demyelinating lesions with larger diameters, some of them presenting gadolinium enhancement; most of lesions from the posterior fossa were confluated. Despite the treatment with antibiotics, methylprednisolone associated with IgG
impaired mobility and lower quality of life. The impact of spasticity on healthcare utilization (HCU) is poorly understood. Objective: Assess association of spasticity and HCU among North American Research Committee on Multiple Sclerosis (NARCOMS) registry participants. Patients and methods: NARCOMS maintains a self-report database of MS patients who volunteer health-related information through online or paper questionnaires at enrollment and semi-annually thereafter. Among 5172 individuals who completed surveys in 2005 and 2011, we evaluated the association of HCU with spasticity reported using the 5-point Performance Scales spasticity subscale (PSss). Results: Responders were predominantly female (76.2%) and white (96.2%). In 2005 mean (SD) age was 52 (9.8) years, disease duration 13.7 (9.1) years, and 50.8% could walk unassisted. 18.8% reported no spasticity, 36.2% minimal, 17.5% mild, 15.7% moderate, 9.9% severe and 1.9% total. In the prior 6 months, 653 (13.2%) reported an ER visit while 358 (7.1%) reported hospitalization. Frequencies for both increased with spasticity severity (p b 0.001 for linear trend). Over 6 years, PSss improved or remained stable in 74.9% and worsened in 25.9%. Versus participants whose PSss score worsened, those with improved spasticity were less likely to report an ER visit (OR 0.83; 95%CI: 0.67-1.03) or hospitalization (OR 0.76; 95%CI: 0.59–0.99) even after accounting for disability and sociodemographic factors. Conclusion: More severe spasticity is associated with greater HCU, emphasizing the adverse impact of spasticity and suggesting that effective treatment of spasticity might reduce HCU. doi:10.1016/j.jns.2013.07.1371
Abstract — WCN 2013 No: 2462 Topic: 6 — MS & Demyelinating Diseases Absence of delayed facilitation and post-exercise facilitation at early stage of multiple sclerosis: Evidence of altered cortical plasticity? S. Simeoni, I. Pittaro-Cadore, V. Russo, A. Fontana, G.L. Gigli, A. Scalise. University of Udine Medical School, Neurology, Udine, Italy Background: By means of transcranial magnetic stimulation (TMS) multiple sclerosis (MS) has been studied. Disabilities correlate with alterations of TMS parameters such as prolonged central motor conduction time, prolonged motor evoked potential (MEP) latencies and increased motor threshold (MT). TMS has also been used to explore movement-related cortical plasticity. Objective: To compare cortical excitability in patients at early stage of MS versus healthy controls. Material and methods: In each subject TMS of non-dominant hemisphere was used to define MEP amplitude and motor threshold (MT). Then subjects performed 3 blocks (30-s, 60-s, and 90-s duration) of a bimanual motor task (exercise condition). Amplitudes of MEPs elicited immediately after each block, and then after a 15-minute rest period were compared with baseline to evaluate the presence of postexercise facilitation and delayed facilitation. Patients were not receiving any therapy and their Expanded Disability Status Scale score was between 1 and 2.5. Results: MT resulted significantly higher in patients compared to controls. Compared with baseline, controls had larger MEP amplitudes after 30 and 60 s of exercise (post-exercise facilitation) and also after the rest period (delayed facilitation). In contrast, MEP amplitudes in patients were not significantly different from baseline after any of the exercise conditions or following the rest period. Conclusion: Patients do not show the normal fluctuations of cortical excitability usually found after a bimanual finger motor task. These
e377
results suggest an alteration in the cortical plasticity. We speculate that in SM patients capability to recover from functional impairments caused by demyelination is compromised. doi:10.1016/j.jns.2013.07.1372
Abstract — WCN 2013 No: 2431 Topic: 6 — MS & Demyelinating Diseases Transorbital sonography in the hyperacute stage of optic neuritis: A bicentric case–control longitudinal, blind study P. Lochnera,b, R. Cantellob, L. Coppob, R. Nardonea, F. Tezzona, O. Raymkulovab, M. Leoneb, F. Brigoa,c. aDepartment of Neurology, General Hospital of Merano, Merano, Italy; bDepartment of Neurology, University A. Avogadro, Novara, Italy; cDepartment of Neurological, Neuropsychological, Morphological and Movement Sciences, Section of Clinical Neurology, University of Verona, Verona, Italy Background: Acute unilateral optic neuritis (ON) is known to be associated with an increased optic nerve sheath diameter (ONSD) as revealed by ultrasonographic investigations. However, there is no consensus in the literature on the diagnostic cut-off of ONSD. Objective: The goals of this study were to evaluate the accuracy/ sensibility of US in the diagnosis of acute ON, and to assess the association between ONSD threshold and ON. Patients and methods: A prospective blinded observational (case– control) bicentric study was performed. Seventeen consecutive patients with an acute non-compressive unilateral ON and onset of visual loss during the prior 10 days were included. We enrolled 20 healthy controls, matched by gender and age (±5 years). Two experienced vascular sonographers, blinded to the status of case or control and to the affected eye, performed the study using B mode US. ONSD was defined as a sign of nerve thickening, if the difference in nerve diameter of 0.3 mm or more, compared with the contralateral side or controls. Results: A significant ONSD increase on the affected compared to the health side, was found in all patients by both investigators (6.6 mm ± DS 0.85 versus 5.5 mms ± DS 0.66 p b .001). ONSD was normal in all controls (5.2 ± DS 0.62) mm and in all the non-affected eyes. Conclusions: Our findings suggest that transorbital sonography has a very high sensitivity in recognizing ON, similar to that of the visual evoked potentials. doi:10.1016/j.jns.2013.07.1373
Abstract — WCN 2013 No: 2460 Topic: 6 — MS & Demyelinating Diseases Klüver–Bucy Syndrome in a multiple sclerosis patient J.P.R.P.T. de Azevedoa, G.L. Vasquesa, C.D. Rochab, J.A.D.O. Júniorb, F.O. Gomesb, D.S. Diniza. aHospital das Clínicas, Universidade Federal de Goiás, Goiânia, Brazil; bFaculdade de Medicina, Universidade Federal de Goiás, Goiânia, Brazil Background: Multiple sclerosis (MS) can result in a complex net of neuropsychiatric symptoms. Klüver–Bucy Syndrome (KBS) is a rare complex behavioral syndrome. It's composed of psychic blindness, hyperorality, hypermetamorphosis, hypersexuality, disturbed dietary habits and placidity. It's widely related to temporal lobe lesions. Objective: Report the rare association between Multiple Sclerosis and Klüver–Bucy Syndrome. Material and methods: Case report.
e378
Abstracts / Journal of the Neurological Sciences 333 (2013) e358–e421
Results: A 32 year old woman diagnosed with MS by the age of 20 started a multiple incipient behavioral change. She was already in Secondary-Progressive phase of the disease. She presents with placidity, hyperorality, hypermetamorphosis and a complex disturbed dietary habit. She used to avoid non-sweet and usually add sugar or sweetener in all kinds of food. The MRI showed diffuse cerebral atrophy especially in the temporal lobes with poor inflammatory lesion in both of them. Topiramate and valproic acid were introduced and controlled well the sweet compulsion. Antipsychotics were tried in other behavioral symptoms. Conclusion: MS is a complex disease composed of both inflammatory and degenerative lesions. Neuropsychiatric symptoms can be related to both of them. There is a complex role of cognitive and special behavioral symptoms that compose MS spectrum, as KBS is shown in this abstract. doi:10.1016/j.jns.2013.07.1374
Abstract — WCN 2013 No: 2403 Topic: 6 — MS & Demyelinating Diseases Disability due to multiple sclerosis in Ukraine (10 year experience) V.A. Golyka, A.V. Ipatova, N.O. Gondulenkoa, A.P. Pivnykb, V.O. Pogorelovaa, N.E. Madyukovaa. aNeurology and Border States, Ukrainian State Institute of Medical and Social Problems of Disability, Dnepropetrovsk, Ukraine; bNeurorehabilitation, Ukrainian State Institute of Medical and Social Problems of Disability, Dnepropetrovsk, Ukraine Multiple sclerosis (MS) is one of the leading causes of permanent disability due to neurological conditions in young adults. Methods: 10 year (2003–2012) dynamics of MS prevalence and disability incidence rates for adult population (all per 100,000) was investigated. Disability grade (“invalidity” status) in Ukraine is set according to the Ministry of Health Order (no. 561, August 05, 2011) based on ICF (2001) principles. We compared MS prevalence (Ukraine Ministry of Health Statistics Dept.) and primary disability data structure due to MS and encephalomyelitis (IDC X codes G35, G36–37) in Ukrainian regions. Results: Global panukrainan MS prevalence was gradually increased (48.0–47.8–48.4–49.1–50.0–50.1–50.9–51.6–52.9–54.6) as well as MS disability incidence (2.4–2.4–2.6–2.7–2.6–2.5–2.6–2.9–3.0–3.1). We also discovered (the data are not collected in clinical statistics) the relatively high rates of disability incidence due to demyelinating encephalomyelitis (total rates 1.3–1.2–1.3–1.1–1.2–1.2–1.0–1.0–1.1– 0.9 for years 2003–2012 accordingly). Conclusions: Further disability data investigation should be performed for understanding the correctness of demyelinating encephalomyelitis diagnostics and protection from MS false negative diagnostics followed by improper expert-rehabilitation tactic. doi:10.1016/j.jns.2013.07.1375
Abstract — WCN 2013 No: 2321 Topic: 6 — MS & Demyelinating Diseases Magnitude and concurrence of anxiety and depression among attendees at tertiary care neurology unit in Oman with multiple sclerosis (MS) A. Al-Asmia, S. Al-Rawahib, Z. Al-Muqbalib, R. Nandhagopala, P.C. Jacobb, A. Gujjarb, S. Al-Adawib. aSultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman; bCollege of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
Background: Anxiety and depression are commonly reported by persons with multiple sclerosis (PwMS) but no data, to our knowledge, have emerged from Arab Islamic population. Objective: The study aims to investigate the prevalence of anxiety and depression among PwMS attending tertiary care hospital in Oman, Neurology Clinic, Sultan Qaboos University Hospital (SQUH). The characteristics such as socio-demographic and clinical variables were also explored. Methods: Consecutive and consenting PwMS were subjected to the following measures. The Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety (cut-point N 7) and depression (N7). Results: 54 patients with MS participated in our study and approximately 87% were on Interferon. The age range from 17 to 50 and the average age was 31.4 ± 8.84. In terms of gender, majority were female (males = 30% vs. 70% females). Approximately 50% of the attendees have acquired university or higher graduate education while 39% had completed secondary education. The rest acquired on the lower strata of education with one illiterate. The majority (69%) of attendees were married while 31% were single. Approximately 83% were employed, students or job-seekers. The majority of the patients had b4 in the EDSS. Prevalence of anxiety was 53%, depression 39% on HADS. Conclusions: Anxiety and depression are common in PwMS among the attendees of tertiary care in Oman. Such psychosocial variables have been largely unreported from non-western population. As these variables are strong indicators of burden of MS, concerted efforts are needed to address such psychosocial dysfunctions in the algorithms of care for PwMS. doi:10.1016/j.jns.2013.07.1376
Abstract — WCN 2013 No: 2394 Topic: 6 — MS & Demyelinating Diseases Acute disseminated encephalomyelitis (ADEM) – probably triggered by Borrelia burgdorferi infection – with fatal end I. Vargaa,b, D.I. Mineaa,b, R.M. Lupua, M. Mihaia, A. Dinua. aNeurology, Neuro-Psychiatry Hospital, Faculty of Medicine, Brasov, Romania; b Neurology, Transilvania University, Faculty of Medicine, Brasov, Romania Background: Acute disseminated encephalomyelitis (ADEM) is a nonvasculitic inflammatory demyelinating condition that usually occurs following a viral, bacterial or parasitic infection, or even spontaneously. Case presentation: We present a case of a patient of 48, who presented the onset of the actual disease with low-grade fever, fatigability, impaired gait and balance, symptoms debuted 2 months before he was admitted in our hospital. Neurological examination revealed bilateral cerebellar and pyramidal syndrome, thermo-algic hypoesthesia below T4 level and urinary incontinence. Cerebral MRI showed bilateral supraand infra-tentorial demyelinating lesions, some of it with gadolinium enhancement and cervico-thoracal MRI revealed extended thoracal myelitis; lumbar puncture showed CSF with pleocytosis and highlights the presence of IgG anti-Borrelia antibodies. We considered the infection with Borrelia burgdorferi as a possible “trigger” factor in apparition of ADEM. The evolution was initially with improvement of symptoms on treatment with cephalosporin and high doses of metilprednisolone. After 2 months, the patient presented sudden motor deficit in the inferior limbs with impairment of the gait and slurred speech. Cerebral and spinal MRI showed more demyelinating lesions with larger diameters, some of them presenting gadolinium enhancement; most of lesions from the posterior fossa were confluated. Despite the treatment with antibiotics, methylprednisolone associated with IgG