Refractory epilepsy following natalizumab associated PML.

Natalizumab treatment of multiple sclerosis (MS) is associated with a risk of developing progressive multifocal leukoencephalopathy (PML), a rare opportunistic viral demyelinating disease caused by reactivation of John Cunningham virus (JCV). Herein, we report a case of a 40-year-old woman who developed refractory temporal lobe epilepsy; one year after recovery form Natalizumab-induced PML. Localisation related epilepsy, which may be refractory in nature, as in this case report, is a potential chronic disabling complication of PML. Epilepsy in this context, likely reflects grey matter involvement, which may then act as cortical epileptogenic zone.

Cheiro-oral syndrome.

We describe a 64-year-old man who presented to the emergency department with a two-day history of left perioral and hand numbness. Examination revealed impaired sensation of the left corner of the mouth and ipsilateral fingers. Neuroimaging showed an acute right thalamic lacunar infarct consistent with the diagnosis of cheiro-oral syndrome. In this report, we discuss the importance of recognising this syndrome and instituting appropriate management to prevent further cerebrovascular events.

CLIPPERS and the need for long-term immunosuppression.

Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS) is a rare chronic inflammatory disorder of the central nervous system. Herein, we describe the case of a 62-year-old female who presented with right sided facial tingling, gait ataxia and diplopia. Neuroimaging revealed pontine curvilinear enhancing lesions with extension into cerebellar peduncles, characteristic of CLIPPERS. This report discusses the differential diagnosis and the importance of prolonged immunomodulatory treatment for this rare neuro-inflammatory disorder. Long-term immunosuppression appears to be mandatory in order to achieve sustained remission and prevent disability related to atrophy of the structures involved in repeated attacks.

Getting a handle on complicated migraine.

We describe a case of a 45-year-old man who presented with a transient syndrome consisting of headache with neurological deficits. Neuroimaging including brain angiography was normal. Cerebrospinal fluid (CSF) analysis revealed an elevated protein and lymphocytic pleocytosis. The diagnosis of a syndrome of Headache and Neurological Deficits with CSF Lymphocytosis (HaNDL) was made after excluding all the other possible causes for the patient's presentation. He made an excellent recovery following a short course of naproxen sodium.