Spinal Myoclonus, Palatal Myoclonus as an Unusual Presentation of Multiple Sclerosis: Case Report

Introduction: Spinal myoclonus (propriospinal myoclonus) originate from spinal cord and take the form spinal segmental myoclonus. Which produces generalized axial jerks that usually begin in the abdominal muscles. Spinal myoclonus usually spontaneous and may persist during sleep, it can involve a single limb, both legs or a limb and adjacent trunk. Spinal myoclonus can result from injury to cord due to infection, tumor, demyelinating disease, fallow spinal anesthetic or introduction of contrast into the CSF. Palatal myoclonus (PM) is characterized by rhythmic movements of the soft palate. Depending the presence or absent of structural lesion of the brainstem, PM divided to essential PM (EPM) and symptomatic or secondary PM (SPM). Stroke is the most common cause of SPM. But trauma, tumor or demyelinating disease (MS) also lead to PM.Case I: A 31 year-old male presented with a 2 month history of brief involuntary jerking of the left shoulder and arm, which persisted during sleep. In retrospective, he developed mild weakness of right lower limb one year ago, neurologic examination revealed myoclonic jerks at left shoulder and wasting of paraspinatus, biceps, deltoid and brachio radialis muscles, weakness of proximal left upper limb (grade 4.5) and right lower limb (grade 3/5), he had exaggerated deep tendon reflexes and extensor planar responses, sensory examination were unremarkable.Biochemical laboratory investigation and laboratory tests for rule out secondary cause of myoclonus such as infections disease (HIV, HSV, HTV182, and syphilis), autoimmune profile and paraneoplastic panel all were negative. Brain MRI shows periventricular plaques and in spinal cord MRI there were demyelinating plaques at C3 and C5 spinal levels corresponding to involuntary movements, examination of cerebrospinal fluid (CSF) revealed oligoclonal bands. Nerve conduction study (NCS) was normal whereas needle electromyography (EMG) revealed rhythmic irregular burst discharges in motor units of muscle expanding from the third to the sixth cervical region. Electronecephalorgraphy (EEG) was normal. According to the revised MC Donald criteria patient was diagnosed as MS.Conclusion: Spinal myoclonus and palatal myoclonus can an unusual presentation of MS. Case II: A 33 year- old woman that was a known case of MS, this time develop PM. Brain MRI demos rated demyelinating plaque in the pons.Conclusion: In MS plaques in brain stem within the Gullain- Mollaret triangle can cause, platal myoclonus.

Keywords:

Spinal myoclonus , Palatal myoclonus , Multiple sclerosis