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\begin{document}

\title{Central positional vertigo as first initial multiple sclerosis symptom:
a case report with systematic review.}



\author[1]{Mostafa Meshref}%
\author[2]{Ahmed  Shaheen }%
\author[3]{Abdelmagid  Elmatboly }%
\author[3]{Aboalmagd  Hamdallah }%
\author[3]{Walid  Abdella }%
\author[4]{Yara  Amro }%
\author[5]{Shiamaa  Khairat}%
\author[6]{Sarya Swed}%
\affil[1]{Al-Azhar University}%
\affil[2]{Alexandria University Faculty of Medicine}%
\affil[3]{Al-Azhar University Faculty of Medicine}%
\affil[4]{Cairo University Faculty of Pharmacy}%
\affil[5]{King Khalid Military City Hospital}%
\affil[6]{University of Aleppo Faculty of Medicine}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\selectlanguage{english}
\begin{abstract}
Multiple sclerosis is a disease that affects the central nervous system,
resulting in a variety of symptoms such as vision , physical activity
and stability .Central positional vertigo as an initial multiple
sclerosis symptoms is a rare case in the literature.%
\end{abstract}%



\sloppy


\textbf{Central positional vertigo as first initial multiple sclerosis
symptom: a case report with systematic review.}

Mostafa Meshref \textsuperscript{1}, Ahmed Shaheen \textsuperscript{2},
Abdelmagid M. Elmatboly \textsuperscript{3}, Aboalmagd
Hamdallah\textsuperscript{4}, Walid Shaban Abdella \textsuperscript{5},
Yara Amro\textsuperscript{6}, Shiamaa M. Khairat\textsuperscript{7} ,
Sarya Swed\textsuperscript{8}.

1-Msc neurology, Faculty of medicine Al-Azhar University, Cairo, Egypt

Email: mostafameshref1988@gmail.com

2- Alexandria Faculty of medicine, Egypt

Email: ahmeds1999haheen@gmail.com

3- Faculty of Medicine, Al-Azhar University, Cairo, Egypt.

Email: abdelmagidmohammed@azhar.edu.eg

4- Faculty of Medicine, Al-Azhar University, Damietta, Egypt.

Email: dr.aboalmagd@gmail.com

5- Faculty of Medicine Al-Azhar University, Damietta, Egypt.

Email: walid.abdella.1997@gmail.com

6- Pharmacist ministry of health, Cairo, Egypt

Email : yaraamro26@gmail.com

7- Division of Neurology medicine, Department of Internal Medicine, King
Khalid Hospital Hail, Saudi Arabia.

Email: ~Shaimaa\_khirate@hotmail.com

8- Faculty of Medicine , Aleppo University , Aleppo , Syria

Email : \emph{saryswed1@gmail.com}

\textbf{*Corresponding author}

Sarya Swed \emph{{[}saryswed1@gmail.com} {]}

Faculty of Medicine , Aleppo University , Aleppo , Syria

\textbf{Abstract}

Multiple sclerosis is a disease that affects the central nervous system,
resulting in a variety of symptoms such as vision ,~physical
activity~and stability .Central positional vertigo as an initial
multiple sclerosis symptoms is a rare case in the literature which it
increases the attention of clinical doctors to follow accurate
measurements to diagnosis multi sclerosis regarding the initial
symptoms.

\textbf{Keywords}

Central positional vertigo , multiple sclerosis , case report and
systematic literature review .

\textbf{Introduction}

Multiple sclerosis (MS) is one of the most common and best-known
demyelinating disease with peak incidence between 20 and 30 years of age
(1). MS has a wide range of presentation and equal wide range of
prognosis. Classically, MS is diagnosed by finding multiple white matter
lesion separated by space and time while, the clinical features are
defined by the location of lesion. Common clinical features include
corticospinal tract signs (weakness and spasticity), sensory
abnormalities, and cerebellar dysfunction (intention tremors and ataxia)
(2). In patients with MS, equilibrium disorders caused by involvement of
brainstem and cerebellar structures are common and about 20\% of MS
patients representing by true vertigo at some time during the disease.
However, peripheral conditions such as benign paroxysmal positional
vertigo (BPPV) and central positional vertigo were also reported (3).
Therefore, an accurate otoneurologic investigation paying attention to
differentiate between central and peripheral cause. Central positional
vertigo associated with MS could be easily misdiagnosed as BPPV. It
could be difficult if it occurred as the initial MS symptoms to
differentiate it from BPPV. The Provoking maneuvers like Dix-hall pike
and Supine head roll test results are very crucial in making the
diagnosis (4).

In this article we represented a case of central positional vertigo as
an initial multiple sclerosis symptoms accompanied with systematic
review of previous related cases.

\textbf{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.

\subsection*{}

{\label{section}}

\subsection*{}

{\label{section-1}}

\subsection*{}

{\label{section-2}}

\subsection*{Methods}

{\label{methods}}

This review is performed and reported according to meta-analysis
(PRISMA) guidelines (5).

\subsubsection*{Literature search
strategy}

{\label{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
27\textsuperscript{th}, October 2021.

\subsection*{Eligibility criteria and study
selection}

{\label{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)

\subsection*{}

{\label{section-3}}

\subsection*{}

{\label{section-4}}

\subsection*{Results}

{\label{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.

\subsection*{Discussion}

{\label{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.

\textbf{Case report discussion}

In (Yoosefinejad 2015) they say the patient symptoms were exacerbated by
the Dix-Hallpike maneuver and that lead them to make sure that the
diagnosis was BPPV but we don't know what they mean by ``exacerbation of
symptoms'' they didn't report the duration, direction, latency of the
elicited nystagmus and we can't trust their judgment as central
positional vertigo is still not excluded from the diagnosis which means
the patient's vertigo could be of central cause, in this case, MS as the
patient was previously diagnosed by MS six years before the vertigo
onset.

In Must 2020, as in our case, the patient's vertigo was alleviated by
the use of steroid therapy. Moreover, deep head hanging maneuver was
applied but without any positive result which further suggests the
central cause of vertigo and MS was confirmed by MRI.

The cases reported in this review and our case report suggest that
central positional vertigo associated with MS could be easily
misdiagnosed as BPPV. It may not be that difficult if the case comes
with new-onset positional vertigo after initial diagnosis with MS, but
on the other hand, if the reverse happens as in our case the final
decision of BPPV diagnosis should be carefully taken after ruling out
other possible central causes.

The Provoking maneuvers like Dix-hall pike and Supine head roll test
results are very crucial in making the diagnosis, minute changes or
atypical presentation should raise our susception to central causes, MRI
and CT scans can be good tools to rule out central causes before final
BPPV diagnosis decision is taken in this case. After all, we suggest
more primary research observational retrospective to and clinical trials
should be done to investigate the MS and BPPV association and possible
error in diagnosis.

\subsection*{}

{\label{section-5}}

\textbf{Abbreviations}

MS : Multiple sclerosis

BPPV : Benign paroxysmal positional vertigo

ENT : Ears , nose and throat

MRI : Magnetic resonance imaging

CT : Computed tomography

CPV \textbf{:} central positional vertigo

*\textbf{Acknowledgements}

Our sincere thanks to all the doctors and nurses who participated in the
treatment of this case, and we also thank the patient's parents for
allowing us to reports this case.

\textbf{*Authors' contributions}

All authors have read and approved the manuscript

MM , AS ,AME , AH , WSA , YA , SMK AND SS : Contributed in writing and
reviewing the manuscript.

\textbf{*Ethics approval and consent to participate}

Ethical approval was given by the KING KHALED Hospital. And the patient
has given their Parental consent for this publication.

\textbf{*Consent for publication}

Written informed consent was obtained from the patient for the
publication of this case report and any accompanying images. A copy of
the written consent is available for review by the Editor of this
journal.

\textbf{DATA AVAILABILITY STATEMENT}

\textbf{*} All data (of this patient) generated during this study are
included in this published article and its supplementary information
files.

\textbf{References}

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\tightlist
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\end{enumerate}\selectlanguage{english}
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