Contributions
Abstract: EP1342
Type: ePoster
Abstract Category: Clinical aspects of MS - Diagnosis and differential diagnosis
Background: Diving became a widely practiced leisure sport in the young. Ascents from depths >12m require decompression algorithms (DA) to avoid decompression sickness (DCS) and arterial gas embolism (AGE). A variety of DA exist, while, despite correctly performed,AGE may occur even in shallow depths and asymptomatic cerebral lesions, matching MS-MRI, are found in MRI of frequent divers.
Objective: To show close resemblance of MRI lesions in divers with MS lesions and DCS symptoms with MS relapse.
Results: We describe three suspected cases of MS. A 23-year-old female SCUBA-diver, diagnosed as RRMS, presented 12/11 in Frankfurt for immunomodulatory medication. She showed left-sided hemihypesthesia after two allegedly steroid-refractory relapses and three cerebral FLAIR-lesions at admission. A 43-year-old male, CIS-diagnosed SCUBA-diver was seen 6/12 in Tübingen to receive immunomodulation due to sensitivity-losses of both Arms, neuropsychological deficits and multiple periventricular FLAIR-lesions “compatible with MS”. A 34year old German Navy diver was seen 3/16 in Frankfurt with cerebellar complaints and a MRI suggestive for MS to receive immunomodulation. In all cases, only meticulous interrogation unmasked SCUBA-diving and the actual association of presumed "relapses" with “dirty-ascent”-dives while “relapses” were steroid-refractory and in this sense atypical for classical MS. These confounders led to a diagnostic revision, showing neither CSF- nor electrophysiological signs of inflammatory demyelination. In the Frankfurt cases, a massive, patent oval foramen with bubble transition at rest was found. The Tübingen case showed no cardial pathology, indicating pulmonary shunts. All cases were diagnosed as symptomatic DCS due to AGE and instructed to halt diving. Immunomodulation was postponed. All remained clinically and radiologically stable since.
Conclusion: SCUBA-diving exerts relevant physiological stress on human physiology. DA improve safety but cannot exclude AGE, especially in the presence of PFO. Our cases show morphological resemblance of AGE-MRI with MS-MRI and DCS with relapse symptoms in an equally young population. Radiological red flags for AGE are low lesionload without callosal lesions.
Obtaining the medical history, SCUBA-diving should be considered a MS mimic and, divers should be assessed for PFO using TEE. If positive, immunomodulation should be postponed unless proven further clinical or MRI activity despite halted diving.
Disclosure: UZ has received honoraria from Biogen Idec Deutschland GmbH, Bayer Vital GmbH, CorTec GmbH, Medtronic and Servier for advisory work, and a grant from Biogen Idec for supporting an investigator initiated trial.
CS has nothing to disclose
DA has nothing to disclose
CM received travel grants from NOVARTIS pharma, Biogen Idec and a research grant from NOVARTIS pharma
CF has nothing to disclose
Abstract: EP1342
Type: ePoster
Abstract Category: Clinical aspects of MS - Diagnosis and differential diagnosis
Background: Diving became a widely practiced leisure sport in the young. Ascents from depths >12m require decompression algorithms (DA) to avoid decompression sickness (DCS) and arterial gas embolism (AGE). A variety of DA exist, while, despite correctly performed,AGE may occur even in shallow depths and asymptomatic cerebral lesions, matching MS-MRI, are found in MRI of frequent divers.
Objective: To show close resemblance of MRI lesions in divers with MS lesions and DCS symptoms with MS relapse.
Results: We describe three suspected cases of MS. A 23-year-old female SCUBA-diver, diagnosed as RRMS, presented 12/11 in Frankfurt for immunomodulatory medication. She showed left-sided hemihypesthesia after two allegedly steroid-refractory relapses and three cerebral FLAIR-lesions at admission. A 43-year-old male, CIS-diagnosed SCUBA-diver was seen 6/12 in Tübingen to receive immunomodulation due to sensitivity-losses of both Arms, neuropsychological deficits and multiple periventricular FLAIR-lesions “compatible with MS”. A 34year old German Navy diver was seen 3/16 in Frankfurt with cerebellar complaints and a MRI suggestive for MS to receive immunomodulation. In all cases, only meticulous interrogation unmasked SCUBA-diving and the actual association of presumed "relapses" with “dirty-ascent”-dives while “relapses” were steroid-refractory and in this sense atypical for classical MS. These confounders led to a diagnostic revision, showing neither CSF- nor electrophysiological signs of inflammatory demyelination. In the Frankfurt cases, a massive, patent oval foramen with bubble transition at rest was found. The Tübingen case showed no cardial pathology, indicating pulmonary shunts. All cases were diagnosed as symptomatic DCS due to AGE and instructed to halt diving. Immunomodulation was postponed. All remained clinically and radiologically stable since.
Conclusion: SCUBA-diving exerts relevant physiological stress on human physiology. DA improve safety but cannot exclude AGE, especially in the presence of PFO. Our cases show morphological resemblance of AGE-MRI with MS-MRI and DCS with relapse symptoms in an equally young population. Radiological red flags for AGE are low lesionload without callosal lesions.
Obtaining the medical history, SCUBA-diving should be considered a MS mimic and, divers should be assessed for PFO using TEE. If positive, immunomodulation should be postponed unless proven further clinical or MRI activity despite halted diving.
Disclosure: UZ has received honoraria from Biogen Idec Deutschland GmbH, Bayer Vital GmbH, CorTec GmbH, Medtronic and Servier for advisory work, and a grant from Biogen Idec for supporting an investigator initiated trial.
CS has nothing to disclose
DA has nothing to disclose
CM received travel grants from NOVARTIS pharma, Biogen Idec and a research grant from NOVARTIS pharma
CF has nothing to disclose