92. Paroxysmal Dystonia Presenting as the First Sign of Multiple Sclerosis: A case report

• Published in: Multiple sclerosis and related disorders 2024-12, Vol.92
• Main Authors: Rekia, Adjmi Roumaissa, Ahmed, Hakim Si, Daoudi, Smail
• Format: Article
• Language: English
• ISSN: 2211-0348
• DOI: 10.1016/j.msard.2024.106053

Paroxysmal dystonia is an uncommon but well-recognized movement disorder in the setting of multiple sclerosis. defined by episodic involuntary flexion, extension, or prolonged muscle contractions that usually affect one side of the body if not specific muscle groups. The episodes can last from seconds to many minutes and usually occur due to stress, exhaustion, or unexpected movement. When such paroxysmal symptoms appear as an initial feature of multiple sclerosis, they raise several differential observations sometimes delaying the diagnosis. A 20-year-old female with no previous medical history presented with painful, involuntary muscle spasms in the right upper limb, occurring up to five times a day. The physical examination was unremarkable . MRI of the brain showed multiple bilateral lesions in the periventricular and subcortical white matter and the splenium of the corpus callosum, with some lesions enhancing after gadolinium contrast. MRI of the spinal cord revealed intramedullary lesions in the cervical spinal cord, with slight enhancement in one lesion after gadolinium contrast. Cerebrospinal fluid analysis indicated presence of oligoclonal bands, anti-aquaporin 4 and anti-MOG antibodies were negative. Additional laboratory tests including blood tests, inflammatory markers, thyroid function, autoimmune panel, serological tests, and vitamin B12 levels were all normal and the Electroencephalogram showed no abnormalities. The patient was diagnosed with multiple sclerosis according to the McDonald's (2017) diagnostic criteria. She was treated with high-dose intravenous methylprednisolone for five days and started on carbamazepine 200 mg twice a day. The spasms disappeared within two days of starting treatment and she remained relapse-free for six months following the initiation of Natalizumab disease-modifying therapy. Paroxysmal tonic spasms, though uncommon, can be an initial presenting symptom of MS. These spasms, characterized by brief, recurrent episodes of involuntary muscle contractions, can delay diagnosis and cause significant distress. Early recognition and rapid initiation of antiepileptic treatment, such as carbamazepine, are essential for reducing spasm frequency and severity, often leading to complete symptom resolution. Increased awareness and prompt action by clinicians are crucial, and further studies are needed to refine diagnostic and therapeutic approaches for PTS in MS.