A 49 year old man, was admitted to Seyyed al-Shohada hospital (Aran va Bidgol County, Isfahan Province, Iran) in November 2021 with a chief complaint of a severe throbbing headache at frontotemporal regions at both sides, accompanied by nausea, vomiting, photophobia, and phonophobia; the headache aggravated with walking. He also reported a non-pulsating tinnitus and severe positional vertigo which had lasted a few minutes and limited patient’s walking. About 10 days ago, he presented to a clinic for a vague headache and tinnitus; after evaluation, an elevated blood pressure was detected, and the patient was referred to a cardiologist who had prescribed him losartan. Yet, his symptoms did not improve that much, and he presented to our hospital a day prior to severe headache, and after a period of observation was discharged with reassurance and advice to adherence to his antihypertensive medications, and after one day, the severe headache accompanied by cited symptoms developed. In the past medical there was a hospitalization due to COVID-19 about one year ago, after which he developed shingles; there was no history of migraine or similar headaches in the past. In physical examination, he had a blood pressure of 170/100, a pulse rate of 88, and was afebrile. He was alert and oriented to time, place, and person, and speech was normal. The function of cranial nerves was normal, but in the case of vestibular part of vestibulocochlear nerve there was a unilateral horizontal nystagmus to the right in the right eye, whose direction did not change with altering the gaze direction, but was suppressed by fixation. The Dix-Hallpike and supine roll tests were positive for the right side, and induced the cited nystagmus in the right eye, but the head thrust test was normal. The sensory system seemed intact, but in the motor system the strength of right upper limb and left lower limb was 4/5 in both proximal and distal muscles; when further questions were asked about this weakness, the patient cited that this weakness had developed after shingles about a year ago, and considering it as a consequence of shingles, he had not paid much attention to it. Of cerebellar functions, the finger to nose and heal to shin tests were normal, but assessment of the gait was not possible regarding the vertigo. Common laboratory tests and brain CT were requested; the laboratory tests were normal, but the brain CT showed hypodensities in the white matter of both cerebral hemispheres in the periventricular region and centrum semiovale (Fig. 1); therefore, a subarachnoid hemorrhage or ischemic infarct were mostly ruled out, and medications were administered for relieving the symptoms: labetalol was administered for the elevated blood pressure, acetaminophen for headache, and for vertigo the repositioning maneuvers of Epley and deep head hanging were performed, yet the vertigo did not subside, therefore, betahisitine and cinnarizine were started. After one day, the blood pressure was controlled, but in spite of partial relief, the headache and vertigo still continued; therefore, we decided to perform lumbar puncture (LP), but the patient refused; so, brain MRI was decided as the next step.
Brain MRI showed signs of brain atrophy and ventriculomegaly; furthermore, Hyperintense lesions were observed in the white matter of periventricular and subcortical regions of both cerebral hemispheres as well as in both cerebellar hemispheres and both middle cerebellar peduncles in T2-wheited sections (Fig. 2); one of the lesions in the in the left temporal lobe showed gadolinium enhancement. These lesions necessitated ruling-out vasculitis and demyelination, according to the radiologist’s consult. Brain MRA (magnetic resonance angiography) and brain MRV (magnetic resonance venography) were performed, which were normal. Finally, with a probable diagnosis of RRMS in mind, methylprednisolone 500 mg every twelve hours for three consecutive days was started; after this pulse of corticosteroid, the headache and vertigo completely disappeared, which was in favor of our diagnosis; yet, there was no improvement in his weakness. He was discharged with dimethyl fumarate, and advised to return for follow up. One month later the patient presented to the clinic; he was asymptomatic in this period, yet, the weakness had not improved; he also had a new spinal MRI (but no new brain MRI) which showed demyelinating lesions in right lateral column of spinal cord at C2-C3 and C4-C5 levels, which confirmed the diagnosis of MS.