Rachel M. Thompson, BS
Medical Student
UVM Larner College of Medicine
NYC, New York, United States
Daniel S. Marte, MD
PGY-2 Resident Physician
Icahn School of Medicine at Mount Sinai
New York, New York, United States
Oranicha Jumreornvong, MD
PGY-3 Resident Physician
Icahn School of Medicine at Mount Sinai
New York, New York, United States
Miguel X. Escalon, MD
Program Director
Icahn School of Medicine at Mount Sinai
NY, New York, United States
Pediatric-Onset Multiple Sclerosis
Case Description:
A 15-year-old male presented with 6 months of falls, tremulousness, and disequilibrium. Physical examination revealed cerebellar dysarthria, positive Romberg, finger-to-nose dysmetria, intention tremor, and wide-based unsteady ataxic gait. Following workup, the patient was diagnosed with pediatric onset multiple sclerosis (POMS), continued progression of which led to poor school attendance due to accumulating physical disability, slowed cognition, and depression with visual hallucinations necessitating psychiatric hospitalization. Eighteen months after diagnosis, he was admitted to acute rehabilitation from home with severe ataxia, mild-moderate dysarthria, dysphagia, and mild cognitive impairment. Rehabilitation gains included improved intelligibility with speech exercises focusing on varying expressive tone and pitch, decreased assistance required to ambulate longer distances with a unilateral crutch, and improved balance and management of upper extremity tremulousness through coordination exercises. The patient also received services to address the progressive nature of his condition, including anticipation of future durable medical equipment, home health, and educational accommodations.
Discussions:
This case is atypical for POMS due to the rapid symptom progression, including severe ataxia without significant spasticity, dysarthria, and prominent psychiatric symptoms like depression, hallucinations, and suicidal ideation. The patient also had the uncommon finding of numerous diffuse lesions in the cortex, cerebellum, brainstem, cervical and thoracic spines. His POMS was aggressive and nonresponsive to agents including rituximab and dalfampridine, necessitating the unique scenario of presentation to acute rehabilitation from home. The patient was able to make significant gains in balance, gait and stair navigation, and intelligibility while receiving social services by participating in intensive therapies at acute rehabilitation.
Conclusions:
This is a unique case of severe progressive POMS with rapid early accumulation of disease burden due to cerebellar ataxia, dysarthria, and psychiatric symptoms which illustrates the importance of multidisciplinary rehabilitation intervention with anticipation of future medical and social needs.
