Case report: baló concentric sclerosis in a patient presenting with dyslexia, dysgraphia, and agraphesthesia

Abstract

Introduction: Baló Concentric Sclerosis (BCS) is a rare inflammatory demyelinating disease of the central nervous system. Commonly reported symptoms and its classic neuroimaging findings can lead to a mistaken diagnosis of expanding lesions. The aim is to report on a case of a rare etiology of altered parietal lobe cortical functions, and the importance of topographic reasoning. Review of the patient’s file for clinical history, neurological exam, and complementary tests was performed. Case report: A 36-year-old male patient presented to the emergency room (ER) with complaints of sudden difficulties in reading and writing. He also recalled a perception of numbness on the right side of his body throughout the 15 days before ER evaluation. On neurological exam, the patient presented with dyslexia, dysgraphia, right agraphesthesia, and right hemihypesthesia to all sensory modalities. Magnetic resonance imaging showed a lesion on the left inferior parietal lobe with alternating isointense and hypointense concentric ring-like bands on T1-imaging; hyperintense alternating lamellae on T2-sequences; high signal intensity at the lesion edge on DWI. Its location matched our topographic hypothesis, based on the neurological exam, and its appearance was typical for BCS. We observed other demyelination lesions fulfilling the dissemination in time and space criteria. Cerebrospinal fluid was collected, without infectious signs. Treatment was started with methylprednisolone 1 g/day for seven days and five plasmapheresis sessions. Conclusion: BCS usually presents with subacute elevated intracranial pressure symptoms and classic focal demyelinating deficits, like hemiparesis and ataxia. Unlikely, cortical disturbances can be the main presentation, making topographic reasonig fundamental. Occasionally, BCS has an acute onset, mimicking a stroke event.