Case presentation
A forty-four years old Female patient with co-morbid illnesses. She was
presented two years ago by acute onset severe vertigo lasted for two
days. This vertigo was related to position increased in lying on either
side associated with nausea and recurrent vomiting and inability to
walk. The patient condition was not preceded by viral infection or ear
problem. On examination the patient was conscious, alert, oriented to
date time and persons. There was first degree bilateral horizontal
nystagmus with intact motor, normal planter response, intact sensation
and intact cerebellar examination at that time. The ENT examination was
normal (no middle ear problems, viral infection or vesicles), but there
was positive Dix Hallpike manoeuvre. Patient was admitted combined
neurology and ENT for further evaluation and for MRI brain. The MRI
brain result showed multiple demyelinating patches corresponding to
multiple sclerosis diagnosis (Figure 1a ,1b , 1c). We started her on
pulse steroid therapy for five days with marked improvement. We referred
her for multiple sclerosis specialized centre where they confirm
diagnosis via CSF analysis (oligoclonal bands and IgG index). Patient
was started fingolimod 0.5 mg orally once daily.
Methods
This review is performed and reported according to meta-analysis
(PRISMA) guidelines (5).
Literature search
strategy
We systematically searched data bases: PubMed, Scopus, Web of Science
and Chochrane. The following search term was used for data base search:
(“Benign Paroxysmal Positional Vertigo” OR “Benign positional
vertigo” OR “peripheral vertigo” OR “acute vestibular syndrome” OR
“acute vestibulopathy” OR “Familial Vestibulopathy” OR “Benign
Recurrent Vertigos” OR BPPV) AND (“Multiple sclerosis” OR
“disseminated sclerosis” OR MS). Last literature search was done on
27th, October 2021.
Eligibility criteria and study
selection
To include studies in our systematic review, they must contain original
data about BPPV as first presentation and multiple sclerosis.
And because the data available on his topic is very rare, we decided to
include all studies designs including case reports except litter to
editor, reviews, and comments. Study screening and study selection were
performed by two independent researchers. (Figure 2)
Results
From 339 studies screened, only four studies met the eligibility
criteria for our systematic review. The four studies were case reports
with 32 cases as follows: (25, 5, 1, 1),(Frohman 2000, Thomas 2016,
Musat 2020, Yoosefinejad 2015) respectively (6-8).
Demographic characteristics and clinical data were extracted as in
(Table 1). Age ranges from 31 to 44 years with 19 female cases and 8
male cases. 2 cases were initially diagnosed as BPPV and then found MS
was seen on MRI as white patches. In those two cases, Epley and deep
head hanging maneuver didn’t relieve vertigo but with steroid use in the
second case (Musat 2020) was relived. In (Yoosefinejad 2015) the case
was initially diagnosed with MS 6 years before developing BPPV which was
diagnosed by clinical presentation then they confirmed the diagnoses
after Semont and Epley maneuvers used and significantly relieved the
BPPV.
Discussion
Benign paroxysmal positional vertigo (BPPV) is defined as a disease of
the inner ear characterized by repeated episodes of positional vertigo.
BPPV could be clinically diagnosis by elicitation of nystagmus and
vertigo on provoking maneuvers for BPPV (9). Although provoking
maneuvers are very useful, minute changes in their findings should raise
suspicion of other central causes as it could be easily mixed with
central positional vertigo (CPV). CPV can be, CPN is caused by
cerebellar and/or brainstem dysfunction and can mimic BPPV (10).
For patients with atypical presentation of BPPV, the physician should
consider further investigation with audiometry, vestibular function
testing, and neuroimaging.
Atypical BPPV presentation could be: Vertigo that lasts longer than one
minute, associated hearing loss, Associated neurological symptoms like
gait disturbances or previous history of neurological disorders or
tumors. Failure to respond to canalith repositioning maneuvers or
vestibular rehabilitation therapy.