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Neurocognitive Disorders and Neuropsychiatry

(082) A Neuropsychiatric Approach to Bipolar Disorder due to Multiple Sclerosis with a Lesion of the Splenium

Disclosure(s):
Connor L. Booker, MD: No financial relationships to disclose
Abstract: Background
Multiple Sclerosis (MS) often affects the corpus callosum including the splenium, which can be associated with various neurological and psychiatric disorders (Park, 2017). There are case reports of reversible splenial lesions associated with neuropsychiatric symptoms, but to our knowledge, this is the first reported case describing manic/psychotic symptoms related to a MS induced splenial lesion. We present a unique case of an individual who was diagnosed with bipolar disorder with manic and psychotic features due to MS with a splenial lesion.
Case
The patient is a 25-year-old African-American male with no pertinent medical history, who presented with symptoms of mania and psychosis. Initial work-up was notable for cannabis on urine toxicology along with a hypodensity in the left frontal periventricular white matter on head CT. Subsequent results were significant for MRI with multiple lesions in the periventricular and juxtacortical white matter, along with the right splenium, in addition to demyelinating lesions at cervical and thoracic levels. Other autoimmune work-up was negative. He satisfied McDonalds criteria for diagnosis of MS in addition to lumbar puncture with 8 oligoclonal bands, and was treated with course of IVIG. His psychiatric symptoms were addressed with olanzapine and valproic acid.
Discussion
The lifetime prevalence of bipolar disorder in MS is 8.4% compared to 4.4% in the general population. MS lesions in critical brain areas may contribute substantially to an increased prevalence of bipolar disorder, but there are also possible genetic contributions from the HLA region in those with MS and a family history of bipolar disorder (Joseph, 2021). Splenial lesions can be seen in a wide array of clinical conditions including seizures, substance withdrawal, and neoplasm. Data has shown variable response to psychotropic treatment, highlighting the need for supportive care and addressing the underlying cause (Xu, 2021). This case may serve as a plausible treatment framework moving forward.
Implications
- Highlights the splenium as a target for etiological and diagnostic investigation for psychosis and mania
- Vigilance regarding splenial findings in a neurological disorder may allow for early detection and appropriate management of neuropsychiatric symptoms
- MS lesions are separated by space and time, future research into associations of specific lesions’ concordance with psychiatric symptoms may allow for stratification of risk of developing mania
References
Joseph B, Nandakumar AL, Ahmed AT, Gopal N, Murad MH, Frye MA, Tobin WO, Singh B. Prevalence of bipolar disorder in multiple sclerosis: a systematic review and meta-analysis. Evid Based Ment Health. 2021 May;24(2):88-94. doi: 10.1136/ebmental-2020-300207. Epub 2020 Dec 16. PMID: 33328183; PMCID: PMC10231514.
Park SE, Choi DS, Shin HS, Baek HJ, Choi HC, Kim JE, Choi HY, Park MJ. Splenial Lesions of the Corpus Callosum: Disease Spectrum and MRI Findings. Korean J Radiol. 2017 Jul-Aug;18(4):710-721. doi: 10.3348/kjr.2017.18.4.710. Epub 2017 May 19. PMID: 28670166; PMCID: PMC5447647.
Xu Z, Zhou Z, Jang W, Tian J, Hou G. Reversible splenial lesion syndrome with mental disorders as only manifestation. BMC Neurol. 2021 Sep 15;21(1):356. doi: 10.1186/s12883-021-02391-6. PMID: 34525954; PMCID: PMC8442370.

Presentation Eligibility: Not previously published or presented

Diversity, Equity, and Inclusion: This presentation involves a diverse group of authors and involves a case presentation on an African-American patient, which is a historically marginalized group in medicine. This presentation may advance the understanding of this neuropsychiatric illness or lead to better health outcomes in this patient population.