Sudarshan Mohan
Student Physician
Eastern Virginia Medical School
Norfolk, Virginia, United States
Disclosure information not submitted.
Title: Conversion Disorder to Marburg Variant Multiple Sclerosis - An Unnerving Tale
Case Report Body:
Introduction: Marburg Variant Multiple Sclerosis (MS) is an exceptionally rare disease with a fulminant and often fatal course. The presentation is classically multifocal, including motor and sensory deficits, aphasia, or seizures. We report an interesting case that was initially diagnosed as conversion disorder and had rapid clinical deterioration within a week.
Description: A 22-year-old healthy female presented to the emergency department (ED) after refusing to speak for a day. The family reported a recent job loss as a new stressor. Labs and non-contrast CT head were unrevealing. Examination did not reveal any neurological deficits. A psychiatric evaluation was performed; she was diagnosed with conversion disorder and discharged for outpatient follow-up. Eight days later, she returned to the ED after being found unresponsive. She had developed new-onset right-sided weakness in addition to prior symptoms. Examination was significant for right-sided hemiparesis, clonus, and hyperreflexia. MRI revealed multiple T2/FLAIR hyperintense lesions involving periventricular, subcortical white matter, and central pons. Cervical MRI revealed an enhancing focus in the dorsal right cervical cord at the level of C3. MS panel showed oligoclonal bands. She was started on a five-day course of high-dose steroids. She developed complete ophthalmoplegia on day two; plasmapheresis was initiated. Despite treatment, her neurological deficits worsened, leading to respiratory failure requiring intubation. Repeat MRI revealed significant progression of demyelinating disease with several new lesions in bilateral cerebral hemispheres. She was diagnosed with Marburg Variant MS due to characteristic imaging findings and rapid disease progression. High-dose cyclophosphamide treatment was started but stopped after five days due to significant leukopenia. She was switched to Rituximab and a follow-up MRI showed disease stabilization with no new lesions.
Discussion: MS presenting in young women can be misdiagnosed as conversion disorder. Thorough workup including MRI is essential to avoid missing aggressive demyelinating diseases like the Marburg variant. In fulminant MS, high-dose cyclophosphamide is used when steroids and plasmapheresis do not improve symptoms. Rituximab should be considered for treatment in refractory cases.