Multiple sclerosis vs Lyme disease: A case presentation to a discussant and a review of the literature

A 46-year-old male engineer, married with two children, born in Israel, of Ashkenazi origin, previously healthy, was initially evaluated because of complaints of paresthesias in his hands and legs and in the right part of his face. Subsequently, there was some difficulty in speech, accompanied by blurred vision and an unsteady gait. On examination, behavioral disinhibition and euphoria were noted, accompanied by 'scanning speech' (dysarthria) and pyramidal syndrome (hypereflexia and bilateral Babinsky's signs), without apparent muscle weakness. Mild cerebellar signs were also found (dysmetria in both hands and ataxia). A CT scan of the brain was normal. The putient presented with neurologic symptoms that localized primarily to the brainstem. Paresthesias of all four extremities suggest bilateral involvement of the sensory tracks, whereas involvement of the right-sided face suggests unilateral involvement of the brainstem. The unsteady gait suggests involvement of the cerebellar tracks, although that could relate to sensory systems as well. Difficulties in speech could be either dysarthria, located in the brainstem, or aphasi. Physical examination revealed brainstem findings (scanning speech), pyramidal signs and a oerebellar syndrome. Of note is the disinhibitive and euphoric mood, indicative of higher cortical function involvement. The normal CT scan rules out bleeding. Given the normal CT scan, an MRII should be performed and, depending on the findings, a lumbar punctureo, to rule out an infectious process. MRI showed multiple periventricular hyper intense lesions in the T2-weighted imaging and ventricular enlargement. Increased quantities of IgG antibodies were found in the CSF and oligoclonal bands were found on immunoelectrophoresis. MS was diagnosed and the patient received a high i.v. dose of methyl-