A case study: ADEM-like lesions as a first clinical event in highly active multiple sclerosis

Abstract

Introduction: Multiple sclerosis is an autoimmune cause of neurological disability. Among its risk factors, it may be related to viral triggers. The advent of COVID-19 raises concern as a novel cause of CNS autoimmunity, which may be a response to virus antigens. In this context, we present a case of highly active multiple sclerosis onset two weeks after SARS-CoV2 mRNA vaccination. Case description: A young woman had lower limb paresthesia which quickly evolved into tetraplegia. She had oligoclonal bands on CSF, with cervical myelitis and a brain MRI suggestive of acute disseminated encephalomyelitis. The highest EDSS observed was 9.5 and sustained remission was only achieved after natalizumab treatment was initiated, reaching EDSS 1.5. Discussion: Case evaluation involved the use of plasma biomarkers. While neurodegeneration biomarkers NfL, GFAP, Tau and UCHL1 decreased, the subject appeared to have sustained inflammatory activity with increased CRP, CD-14, TLR4, IL-1β and IL-17A even after remission. Neuroprotective cytokine TGFβ content was also lower. The existence of blackhole-like lesions at first MRI evaluation and individual risk factors in the form of TNF (rs1800629), SOD2 (rs4880) and FCGR2A (rs1801274) gene variants suggest previous subclinical disease, being impossible to define vaccination as a causative factor. Furthermore, review of previously reported cases of MS onset after a SARS-CoV2 vaccine showed a total of 28 cases, with a mean EDSS of 2.44 at the time of worst disability and highly heterogenous exposition intervals. The highest reported EDSS was 3.5. At least 17 subjects achieved remission. Conclusions: Atypical presentations of MS at onset present a challenge which may benefit from precision assays. SARS-CoV2 vaccination appears as a confounder in this case, its relationship with MS activation seeming to be a rare event with low morbidity. The authors understand this case study illustrates how, in an epidemiological standpoint, vaccination benefits still outweigh the risks perceived.