Atypical presentation of juvenile multiple sclerosis in a patient with COVID-19

Abstract

Purpose: To report our experience with a case of a very atypical clinical onset of multiple sclerosis in a young boy during a COVID-19 infection.

Case report: A 16-year-old boy was referred to our ophthalmology clinic with a complete isolated bilateral horizontal gaze palsy. The condition had onset suddenly 2 weeks prior and he had no associated symptoms, as well as no significant medical history. His corrected visual acuity was 0.0 logMAR in both eyes. While hospitalized, he was found infected with COVID-19. Subsequent brain MRI showed multiple lesions typical of a yet undiagnosed MS, as well as an active pontine plaque which was highly probable the cause of the horizontal gaze palsy. High-dose steroid treatment was initiated 1 week later, after the patient exhibited negative COVID-19 test results.

Conclusion: Clinical manifestations of MS are rarely seen in male teenagers and only a few cases of isolated bilateral horizontal gaze palsy have been reported as the initial manifestation, but never during concomitant COVID-19 infection. We presume that the presence of COVID-19 may have been a neuroinflammatory trigger of underlying MS.

Keywords: COVID-19; atypical multiple sclerosis; horizontal Gaze Palsy; pediatric Neuro-Ophthalmology.

Figure 1.

A) Axial computed tomography on admission, at the level of the anterior callososeptal interface, showing unremarkable findings. B) Axial FLAIR image showing a typical hyperintense lesion in the callososeptal interface. C) Axial T1-weighted image obtained after gadolinium administration showing slight enhancement of the lesion in the early phase. D) Sagittal FLAIR image showing that the lesion had propagated along the medullary venules and was perpendicular to the lateral ventricles in a triangular configuration (i.e. Dawson's fingers; arrow); another MS lesion of the occipito-mesial juxtacortical white matter was noted as an incidental finding (arrowhead). E) Coronal T1-weighted image obtained after gadolinium administration showing more pronounced enhancement of the lesion in the late phase.

Figure 2.

A) Axial computed tomography on hospital admission, at the level of the posterior pontine tegmentum lesion, showing unremarkable findings. B) Axial FLAIR image showing a hyperintense lesion, which was responsible for horizontal gaze palsy. C) Axial T1-weighted image obtained after gadolinium administration showing no lesion enhancement. D) Sagittal FLAIR image showing the vertical extent of the lesion in the posterior pontine tegmentum (arrow); another MS lesion in the splenium of the corpus callosum was noted as an incidental finding (arrowhead).