Psychosis, Cognitive Difficulties May Be First Symptoms of RRMS, Case Report Indicates

Psychosis and cognitive difficulties may be initial symptoms of relapsing‐remitting multiple sclerosis (RRMS), a case report says.

“A case report revealing acute onset psychosis and cognitive impairment as primary manifestation in relapsing‐remitting multiple sclerosis” was published in the journal Clinical Case Reports.

Cognitive impairment is one of the clinical symptoms of multiple sclerosis (MS). Depending on the disease phase and type, approximately 40‐65% of MS patients may develop various degrees of cognitive difficulties.

Previous studies have found neuropsychiatric symptoms affect up to 95% of MS patients, with depression being the most common.

Psychosis has been reported as two to three times more common in MS patients than in the general population. However, psychosis is a rare symptom at MS onset. 

In this case report, a 23-year-old Caucasian man was admitted to the hospital after suddenly developing symptoms of psychosis, including agitation, confusion, aggressive self‐harming behavior, paranoia, suicidal thoughts, and reduced cognitive function. 

He also had weakness in his right leg and lacked muscle coordination when walking. He was not able to recognize either his mother or girlfriend.

The patient had no history of drug or alcohol abuse, and no family history of mood or psychotic disorders.

An MRI scan of the brain raised the suspicion of MS. However, cerebrospinal fluid tests for MS markers came back normal. 

Nonetheless, the patient was started on MS treatment with high‐dose intravenous (into the vein) methylprednisolone and six cycles of plasmapheresis (plasma exchange).

The MRI scan was repeated five weeks later and showed a partial recovery of the brain lesion found originally. A new cerebrospinal fluid study at this time showed positive oligoclonal bands and increased IgG index (immunoglobulin G, a type of antibody), which confirmed a diagnosis of RRMS.

At a six-week follow‐up examination, the patient’s cognitive and physical function had returned to near normal and his psychiatric symptoms had resolved completely. He reported only slight concentration difficulties and tiredness. 

The patient was prescribed cladribine (sold as Mavenclad by EMD Serono) and was further followed-up at an MS outpatient clinic.

“In conclusion, acute onset psychosis and cognitive impairment is a significant problem in RRMS,” the researchers wrote, adding that this “case report underscores the importance of early recognition of acute psychosis and cognitive impairment, which could impose a diagnostic challenge in multiple sclerosis.”