Multiple sclerosis associated with Balo-like lesions post-Coronavirus disease 2019

ABSTRACT

Background and Purpose: Balo's concentric sclerosis (BCS) is a rare inflammatory demyelinating disorder of the central nervous system (CNS) characterized pathologically and radiologically by concentric lamella of alternating demyelinated and partially myelin-preserved white matter. Whether BCS is a variant of multiple sclerosis (MS) or a distinct entity remains debatable. Here, we report an unusual case of MS complicated by Balo's lesions, post-Coronavirus disease 2019 (COVID-19), focusing on the evolution ofMRI findings. Methods: Single-case study. Results: The patient is a 42-year-old woman with relapsing-remitting MS diagnosed at age of 19 who was treated with teriflunomide for the past 5 years. She developed a febrile illness and arthralgia for a week;however, COVID-19 testing was deferred. Two weeks later, she presented with vertigo followed by profound right-hemiparesis, gait impairment, and encephalopathy. Cerebrospinal fluid analysis revealed a protein of 56 mg/dl, increased immunoglobulinG(IgG) index, and>l10 unique oligoclonal bands. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) IgG was detected in serum, but viral ribonucleic acid was absent in the CSF. BrainMRI demonstrated, for the first time, several Balo-like and tumefactive lesions, with contrast enhancement and restricted diffusion. She received plasma exchange alternating with pulse steroids, yet was left with ataxic hemiparetic gait. She was later switched to an anti-CD20 monoclonal antibody therapy. Followup brain MRIs showed continuous regression of the tumefactive and Balo-like lesions. Conclusion: This case adds to the emerging spectrum of COVID-19- associated radiological findings regarding inflammatory demyelination in the CNS. It remains unknown whether potential neurotropism of SARS-CoV-2 or parainfectious mechanisms might have contributed to the fulminant disease in our patient.