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Case report: Pseudotumoral multiple sclerosis lesion associated with discontinuous fingolimod treatment

RESUMO

Case report: Female, 26 years old, diagnosed with a Relapsing-Remitting Multiple Sclerosis (RRMS) in 2018 with na episode of right central visual field deficit. She reported two previous episodes in 2012 and 2017, of lower limb paresthesia with progressive improvement and complete remission within thirty days.
In May 2021, she had na episode of paresis in the left side and left visual deficit, involvement of VII, IX and X cranial nerves ipsilateral. She reported have stayed in February and April 2021, without fingolimod. No infectious processes or previous vaccination. Neurological examination showed complete hemiparesis with predominance of the left brachial, AV 20/80 on the left and 20/30 on the right, deviation of the uvula on the right and tongue deviation on the left. EDSS: 8.0 at the time of admission. Complementary tests: cerebrospinal fluid (CSF): 01 cell, proteins: 40, glucose: 53, BOC present. Other exams without changes. Brain magnetic resonance imaging (MRI): tumefactive right nucleocapsar hypersignal with perilesional edema and signs of acute supratentorial inflammatory activity. She received pulse therapy with dexamethasone (200mg/day) for 12 consecutive days with visual and motor defict improvement: left eye AV (20/40), EDSS: 04.
DISCUSSION: Multiple Sclerosis (MS) is the main chronic demyelinating inflammatory disease of the Central Nervous System (CNS). Injuries to myelin, oligodendrocytes, and axons, to varying degrees, are caused by an autoimmune response. Abrupt discontinuation of fingolimod is reported to cause a rebound effect, with increased inflammatory activity, severe flare-ups, and eventually pseudotumor manifestations within 4-12 weeks. Treatment is challenging and pulse therapy with corticosteroids is considered an alternative to treat rebound after discontinuation of fingolimod.
Final comments:: Although a pseudotumoral lesion in MS is always a challenge, in this case report its appearance was due to the abrupt discontinuation of fingolimod. Unplanned discontinuation of this medication, caused by interruption of supply, is a risk for MS patients. The rapid recognition of this manifestation is essential for the institution of the correct therapy.