Oral Cladribine is Effective in the Treatment of Tumefactive Demyelination in Relapsing Remitting Multiple Sclerosis – A Case Report

This case report describes a 32-year old Emirati patient with tumefactive multiple sclerosis (TMS) treated with a short course of cladribine tablets. The patient presented initially with acute onset of progressive gait unsteadiness, lower limb weakness, associated with numbness of four days duration. Neurological examination of right arms and both legs weakness with sensory level at T10. Contrast-enhanced magnetic resonance imaging (MRI) of the brain showed a large tumefactive demyelination with multiple demyelinating lesions in the brain, consistent with a diagnosis of multiple sclerosis. MRI of the spine cervical and dorsal revealed multiple enhancing lesions as well. Cerebrospinal fluid oligoclonal bands were positive, and IgG index was high. Magnetic resonance spectroscopy showed elevation of lactate on short echo time (TE) and elevation of choline on long TE. The patient was treated with pulse steroid followed by oral cladribine as immune reconstitution therapy in the acute phase. The patient showed significant improvement clinically and radiologically to the treatment. The patient was followed up for 2 years and showed excellent resolution of the tumefactive lesion with no new lesions. Immune reconstitution therapy can be an option for treatment of tumefactive demyelination in multiple sclerosis in the acute setting. To our knowledge, there are no reports of the use of immune reconstitution therapies for the treatment of tumefactive lesions in multiple sclerosis.