A rare presentation of atypical demyelination: tumefactive multiple sclerosis causing Gerstmann's syndrome.

BACKGROUND: Tumefactive demyelinating lesions are a rare manifestation of multiple sclerosis (MS). Differential diagnosis of such space occupying lesions may not be straightforward and sometimes necessitate brain biopsy. Impaired cognition is the second most common clinical manifestation of tumefactive MS; however complex cognitive syndromes are unusual. CASE PRESENTATION: We report the case of a 30 year old woman who presented with Gerstmann's syndrome. MRI revealed a large heterogeneous contrast enhancing lesion in the left cerebral hemisphere. Intravenous corticosteroids did not stop disease progression. A tumour or cerebral lymphoma was suspected, however brain biopsy confirmed inflammatory demyelination. Following diagnosis of tumefactive MS treatment with natalizumab effectively suppressed disease activity. CONCLUSIONS: The case highlights the need for clinicians, radiologists and surgeons to appreciate the heterogeneous presentation of tumefactive MS. Early brain biopsy facilitates rapid diagnosis and management. Treatment with natalizumab may be useful in cases of tumefactive demyelination where additional evidence supports a diagnosis of relapsing MS.

CT in children with abdominal cancer: should we routinely include the pelvis?

BACKGROUND: It has been suggested that the pelvis should not be habitually included on abdominal CT examinations, but the potential benefit of such a practice in childhood abdominal malignancies is unknown. OBJECTIVE: To estimate the yield and potential diagnostic benefit of abnormal findings on CT of the pelvis in children with malignant primary tumours in the upper abdomen. MATERIALS AND METHODS: From a paediatric tertiary referral hospital we retrospectively included patients having abdominal CT for primary upper abdominal tumours (1997-2004), the scan range routinely including the pelvis. We reviewed and tabulated any pelvic abnormality, and calculated group proportions with 95% confidence intervals. RESULTS: We identified 230 children (2 days to 17 years old, median 2.9 years). Six (2.6%; 95% CI 0.5-4.7%) had abnormalities in the pelvis that would not have affected clinical management. Four (1.7%; 95% CI 0.1-3.4%) had findings that might have influenced staging, but only one was not detected by other modalities within 1 week of the CT. CONCLUSIONS: Our data suggest that diagnostically significant findings in the pelvis are rare; consequently, the habitual inclusion of the pelvis on abdominal CT for primary malignant tumours in the abdomen is not justified.