A 54-year-old woman with progressive gait disturbance and MRI abnormalities

Abstract

A 54-year-old right-handed woman initially presented in her 30s with a prolonged flu-like viral illness that began abruptly with fever, chills, and myalgias. She had sore throat and fatigue with a relapsing/remitting course over a year with some remission for several months and then another relapse. She had very high titers of Epstein-Barr virus on serologic testing and was given a diagnosis of chronic fatigue syndrome. She had depression and insomnia that responded to fluoxetine and doxepin. Gradually, this illness and other symptoms subsided over several years and she was symptom-free. She began to have some subtle difficulties with balance 3 years prior to presentation at age 51. The gait problem became more apparent 19 months prior to evaluation when she was unable to ballroom dance because of falls. An extensive workup including visual evoked potentials and CSF were reportedly normal. An initial outside brain MRI 1 year before presentation to our clinic showed an unusual pattern of patchy areas of confluent white matter lesions associated with punctate enhancement. Progressively she had difficulty with normal ambulation throughout the day. Repeat brain MRI done 8 months after the first one showed worsening lesions with increasing enhancement. At this point she also started to use a cane for safety and she was treated with 2 weeks of oral corticosteroids without improvement. At the time of presentation, she was using a cane; her gait was mildly wide-based with some accompanying stiffness in the left leg. She also reported numbness in the left arm and leg over the last 6 weeks. She had occasional night sweats, but denied fever, chills, weight loss, or recent travel outside the United States. She denied dry eyes, dry mouth, focal arthralgias, cough, or rash. Her father and sister had migraines and her father had mild cognitive problems. Her …