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Multiple sclerosis (MS) is an immune-mediated demyelinating disorder of the central nervous system. Two-thirds of patients with MS are women of childbearing age.1 The risk of MS onset is high during the post-partum period2 and the post-partum period is also a time of high risk for onset of bipolar disorder.3 The authors report a case of onset of MS following post-partum depressive and manic episodes.

The complaints of the present patient, a 26-year-old woman, started in the first post-partum month. The complaints of the patient, who gave birth to a child with cerebral palsy, were discomfort, malaise, loss of interest, depressed mood, suicidal thoughts and loss of function. The patient was diagnosed with major depressive disorder and was put on sertralin HCl 50 mg/day and hydroxyzine HCl 25 mg/day. The patient discontinued her medications after 1 week and healed spontaneously in 4 months. At 8 months post-partum the patient developed vertigo and nausea, precipitated by stressor factors. She presented to the Neurology Department of Uludag University Medical Faculty (UUMF) and neurological examination indicated bilateral horizontal nystagmus and hypoesthesia in the regions supplied by the maxillary and mandibular branches of the right trigeminal nerve. Cranial magnetic resonance imaging (MRI) showed a 1-cm non-contrast enhanced lesion, hyperintense on T2-weighted and fluid attenuation inversion recovery images, and isointense on T1-weighted images, located parasagittally, within the left parietal lobe. Vertigo and nystagmus reflect a brainstem or cerebellar lesion that was not displayed in this patient using current cranial MRI technology. Color Doppler ultrasound of the vertebral artery, evoked potentials and audiogram were normal. The patient was not diagnosed with MS but was followed up for new development of plaque(s), and betahistidine 2HCL 24 mg/day and Dimenhydrinate 100 mg/day were started for the symptomatic treatment of vertigo. The patient used these medications for approximately 1 month until the complaints disappeared. At 12 months post-partum the patient presented with excessive joyfulness, restlessness, wasteful expenditures of money, loss of appetite, insomnia and grandiose delusions and was diagnosed with bipolar affective disorder–manic attack. She was admitted to the Psychiatry Department of UUMF and treated for 39 days. Remission was achieved with olanzapine 30 mg/day. During outpatient follow up olanzapine was discontinued after 2 months and was replaced by lithium carbonate 1200 mg/day. Cranial MRI taken during her stay at the Psychiatry Clinic was similar to the first one. The patient was assessed by a neurologist who found no abnormality on neurological examination and recommended follow up for demyelinating disease. At 18 months post-partum, after an episode of urinary incontinence lasting for 1 week and blurred vision on the nasal visual field of the right eye, the patient sought medical attention at the Neurology Department of UUMF when total loss of vision in the right eye and orbital pain developed. The patient was hospitalized for optic neuritis and MS exacerbation when neurological examination indicated horizontal gaze nystagmus in both directions (could count fingers at 4 m) and was treated with methylprednisolone sodium succinate 1000 mg/day and omeprazol 20 mg/day for 5 days. The patient was discharged with a medication regimen of 96 mg/day of corticosteroid (used for 9 days) that produced partial remission in 10 days and recovery of vision in 1 month. Oligoclonal Ig bands were detected on isoelectric focusing in serum and cerebrospinal fluid (CSF) samples taken at the time of hospitalization. IgG index was high with CSF protein value of 68 mg/dL and 5 lymphocytes/mm3. Her cervicothoracic MRI performed at 21 months post-partum was normal. Cranial MR images obtained at 18 and 21 months post-partum did not show a new lesion and diagnosis of relapsing remitting MS was established based on McDonalds criteria.

The rates of bipolar affective disorder in MS patients are elevated, with a lifetime risk twofold that of the general population but throughout the literature there are a few case reports of MS developing in patients who had initially presented with bipolar affective disorder.4,5 According to our knowledge, there are no case reports in the literature on MS following post-partum affective episodes. Although both genetic predisposition and environmental factors have been implicated, the etiology of MS is not clearly understood. Post-partum affective disorder can be a premonitory symptom of MS and the relationship between pregnancy, bipolar disorder and MS should be explored.

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