Dados do Trabalho

Título

ONGOING CENTRAL NERVOUS SYSTEM DEMYELINATING MULTIPLE ACTIVE LESIONS POST mRNA VACCINE: CLINICAL AND SERUM BIOMARKER MONITORING

RESUMO

During COVID-19 pandemia, the central nervous system (CNS) involvement was associated with a more severe outcome. In face of these cases, the emerging challenges are the differential diagnosis with inflammatory demyelinating diseases, mainly the multiple sclerosis (MS). Patients with intrathecal synthesis of immunoglobulin G (IgG) and oligoclonal bandas (OCB) during the first demyelinating event distributed in the space, excluding other etiologies, fulfill diagnostic criteria of MS allowing us initiate treatment in the more favorable therapeutic window. Otherwise, vaccines can trigger immune response, probably in individuals with genetic susceptibility, and relapsing events need, in specific cases, to be addressed with modifying drug therapies (DMD). Besides clinical and MRI activity serum biomarkers, light chain neurofilament (NfL) can contribute to decision making.
Here, we presented a case of a 19-years-old female that has been followed up since December 2021, with neurological exams registers, EDSS, neuroimaging, cerebrospinal fluid and plasma analysis. Single molecule array (SIMOA) was used to analyze neurofilament light level chain (NfL) during the last 6 months.
Fifteen days after mRNA COVID-19 vaccine, she presented paresthesia in four limbs, bladder incontinence, appendicular ataxia, visual impairment and mental confuse state. Cranium MRI showed multiple white and grey matter lesions, some of them with mass effect, brainstem and spinal cord lesions, various with gadolinium enhancement. CSF showed 4 cells, protein 38mg%, no viral, fungus or bacterial identification, and Reiber and Felgenhauer diagram showing intrathecal synthesis of Kappa free chain. For the last six months, she remained with active ongoing disease, presented new MRI lesions, several hospitalization events, receiving intravenous methylprednisolone (IVMPN) treatment and plasmapheresis, leading to a partial improvement. In december-13-2021, NfL level was 247.94pg/mL; in January-17-2022, 216.24pg/mL and, in March-07-2022, 271.38pg/mL. The NfL level is correlated with ongoing disease, new MRI lesions and the EDSS score. In May 2022, we initiated treatment with Natalizumab. Acute demyelinating events post vaccine are generally monophasic. This patient fulfills aggressive MS criteria and differential diagnosis with recurrent ADEM here is a challenge to manage treatment. In this context, NfL level, besides clinical and MRI activity contributed to our decision to treatment onset.

Palavras Chave

COVID-19; Multiple Sclerosis; NfL; Vaccine