Multiple sclerosis in a 4-year-old boy: a case report and literature review

Abstract

Pediatric onset multiple sclerosis (POMS) in the very young is a very rare entity and presents a difficult diagnostic challenge due to overlapping signs and symptoms with other diseases. We present a 4-year-old boy who initially presented with right-sided hemiparesis and demyelinating lesions on MRI. Follow-up MRI examinations 3 and 6 months later revealed new demyelinating lesions. Ten months after initial presentation, he presented with right-sided hemiparesis, central facial nerve palsy on the right side and new demyelinating lesions on MRI. Two clinical events and new MRI lesions on follow-up MRIs confirmed the diagnosis of POMS. He was treated with rituximab and experienced no further relapses or radiological progression during the follow-up period.

Full text

Frontiers in Neurology 01 frontiersin.org
Multiple sclerosis in a 4-year-old
boy: a case report and literature
review
UlaArkar
1, TinaVipotnik Vesnaver
2, DamjanOsredkar
1,3,
MirjanaPerković Benedik
1 and NeliBizjak
1
*
1 Department of Child, Adolescent and Developmental Neurology, University Children’s Hospital,
University Medical Centre Ljubljana, Ljubljana, Slovenia, 2 Department of Radiology, University Medical
Centre Ljubljana, Ljubljana, Slovenia, 3 Faculty of Medicine, Center for Developmental Neuroscience,
University of Ljubljana, Ljubljana, Slovenia
Pediatric onset multiple sclerosis (POMS) in the very young is a very rare entity and
presents a dicult diagnostic challenge due to overlapping signs and symptoms
with other diseases. Wepresent a 4-year-old boy who initially presented with
right-sided hemiparesis and demyelinating lesions on MRI. Follow-up MRI
examinations 3 and 6 months later revealed new demyelinating lesions. Ten
months after initial presentation, he presented with right-sided hemiparesis,
central facial nerve palsy on the right side and new demyelinating lesions on
MRI. Two clinical events and new MRI lesions on follow-up MRIs confirmed the
diagnosis of POMS. Hewas treated with rituximab and experienced no further
relapses or radiological progression during the follow-up period.
KEYWORDS
multiple sclerosis, pediatric onset multiple sclerosis, very early onset multiple
sclerosis, disease modifying therapies, rituximab
Methods
We conducted a comprehensive review of the relevant scientic literature. e search was
conducted using PubMed, Scopus, and Google Scholar databases. e literature search was
conducted in two steps. First, a naive search was conducted using Boolean search queries. No
lters or other search restrictions were applied. e last search was conducted in March 2023.
e nal selection of the top-k studies was done manually by the authors (UA and NB).
Weincluded case reports, case series, original research articles and review articles.
Literature review
Pediatric onset multiple sclerosis (POMS), dened as multiple sclerosis (MS) with onset
in patients younger than 18 years, occurs in 3–10% of all MS patients (1). e incidence varies
by country and is estimated to range from 0.57 to 2.85/100000 children (2–5). Onset before
the age of 10 is extremely rare (6–9) with an incidence of 0.2–0.7% (10).
Clinical presentation
Unlike older children and adults, prepubertal children are more likely to present with
brainstem involvement (1, 8) as well as polyfocal decits and encephalopathy (11), making it
OPEN ACCESS
EDITED BY
Silvia Noemi Tenembaum,
Garrahan Hospital,
Argentina
REVIEWED BY
Grace Yoonheekim Gombolay,
Emory University,
UnitedStates
Amin Zarghami,
University of Tasmania,
Australia
*CORRESPONDENCE
Neli Bizjak
nelika.bizjak@gmail.com
RECEIVED 22 December 2023
ACCEPTED 12 March 2024
PUBLISHED 22 March 2024
CITATION
Arkar U, Vipotnik Vesnaver T, Osredkar D,
Perković Benedik M and Bizjak N (2024)
Multiple sclerosis in a 4-year-old boy: a case
report and literature review.
Front. Neurol. 15:1359938.
doi: 10.3389/fneur.2024.1359938
COPYRIGHT
© 2024 Arkar, Vipotnik Vesnaver, Osredkar,
Perković Benedik and Bizjak. This is an open-
access article distributed under the terms of
the Creative Commons Attribution License
(CC BY). The use, distribution or reproduction
in other forums is permitted, provided the
original author(s) and the copyright owner(s)
are credited and that the original publication
in this journal is cited, in accordance with
accepted academic practice. No use,
distribution or reproduction is permitted
which does not comply with these terms.
TYPE Case Report
PUBLISHED 22 March 2024
DOI 10.3389/fneur.2024.1359938

Arkar et al. 10.3389/fneur.2024.1359938
Frontiers in Neurology 02 frontiersin.org
dicult to distinguish MS from acute disseminated encephalomyelitis
(ADEM), which is much more common in children younger than
10 years (10, 12). Huppke et al. compared 47 prepubertal and 41
postpubertal MS patients. e prepubertal patients were more likely
to have a polysymptomatic severe rst episode with motor and
brainstem involvement, sphincter dysfunction, and cognitive
disturbances, whereas the postpubertal patients predominantly
presented with optic neuritis and sensory symptoms. ey found no
gender prevalence in prepubertal children (8). Öztürk etal. compared
patients with preschool and school age onset (30 children). ey
observed a higher rate of motor symptoms and more attacks in the
rst year in preschool children (13).
Radiologic and laboratory findings
Prepubertal patients also have unique CSF proles and imaging
ndings (14). Chabas et al. found specic CSF ndings with
neutrophilic pleocytosis, higher proportion of monocytes, and
absence of IgG synthesis in younger children with POMS (15). ey
found that changes in CSF immunoglobulins appeared more
frequently with later relapses in children with disease onset under
10 years of age, whereas oligoclonal bands tended to become positive
with increasing disease duration (15).
Prepubertal cases also have unique radiologic ndings. e
T2-bright foci on initial brain MRI tend to beill dened and not
ovoid, the deep gray matter is more frequently aected, and the
number and size of T2-bright foci decrease dramatically on follow-up
scans compared with teenagers (16).
Diagnostic criteria
For the diagnosis of MS, the 2017 revised McDonald criteria (17)
are currently used. e criteria are most applicable to patients older
than 10 years. In younger patients, because of the far more common
occurrence of ADEM, the criteria cannot beapplied at the time of the
rst demyelinating attack and a second relapse characteristic of MS is
necessary to conrm the diagnosis (17).
Early case series and case reports
ere are only a few recent case series of children with very early
onset MS. Some case series were published several years ago (6, 7). It
is important to emphasize that these case series were published before
testing for MOG and aquaporin-4 antibody titers became widely
available and recognized in clinical practice. Ruggieri etal. published
an article in 1999 describing a cohort of 49 children with POMS under
6 years of age. In their cohort, 63% of the children experienced their
second relapse in less than 1 year, and during the follow-up period
(mean duration 6.8 years), only 64% had complete recovery (6).
Individual case reports of very young patients with POMS who were
treated only with methylprednisolone for relapses and had a poor
neurological outcome have also been published (18). Although these
studies describe well the natural course of POMS with very early
onset, they do not tell us much about the prognosis of children
diagnosed and treated today given the numerous new
therapeutic options.
Many case reports also emphasize that diagnosis in patients with
very early onset is oen delayed. Sivaraman etal. described a patient
with onset of MS at a very young age of 2 years and 1 month (10). She
presented with acute onset of ataxia without encephalopathy. Her
brain MRI revealed extensive white matter lesions that were
disseminated in space, whereas her CFS was normal. She was
misdiagnosed as having ADEM. She experienced two further relapses,
and only aer she was evaluated at another hospital for a second
opinion, the diagnosis of POMS was established. Brain MRI revealed
new areas of demyelination at each presentation, while oligoclonal
bands remained negative. Treatment was not reported (10).
Treatment
POMS also presents a treatment challenge (14) because of the lack
of safety and ecacy data for disease-modifying therapies (DMTs) in
children (19). In recent years, the treatment approach with early high-
ecacy therapy (HEET strategy) has become more widely accepted in
POMS than escalation regimen (19, 20), providing better disease
activity control (19). For prepubertal patients, MyGinley et al.
recommend the use of rituximab as rst-line therapy, with
maximization of dose and shortened treatment intervals for
breakthrough disease activity (14). Treatment of POMS with
rituximab is o-label (14, 21). In addition, the use of anti-B-cell
therapies requires long-term follow-up to minimize the risk of serious
adverse events, particularly the risk of immunoglobulin deciency,
malignancies, and infections (14). In children, some studies also
suggest an increased risk of hypogammaglobulinemia with rituximab
therapy (22, 23).
Multiple sclerosis in children under 10 years of age is extremely
rare, and diagnosis is oen delayed. Although there are some
treatment recommendations for prepubertal children, treatment
decisions are still largely dependent on local clinical practice.
Wepresent the case of a four-year-old boy with MS who was treated
with rituximab and experienced no further relapse during the
follow-up period.
Case report
e patient presented to our pediatric neurology department at
the age of 4 years and 6 months aer experiencing 1 week of progressive
right-sided hemiparesis. e parents reported that the boy had been
clumsy for a week before admission. On the morning of the day of
admission, hecould no longer grasp objects with his right hand,
hecould no longer li things, and they noticed an increasing limp in
his right leg. Heis the third child of non-consanguineous parents. His
mother had clinically isolated syndrome (CIS) 10 years earlier – she
experienced one episode of optic neuritis with demyelinating lesions
seen on head MRI that did not fulll the criteria for dissemination in
Abbreviations: MS, multiple sclerosis; CNS, central nervous system; POMS, pediatric
onset multiple sclerosis; ADEM, acute disseminated encephalomyelitis; CIS,
clinically isolated syndrome; DMTs, disease modifying therapies; IVIG, intravenous
immunoglobulins.

Arkar et al. 10.3389/fneur.2024.1359938
Frontiers in Neurology 03 frontiersin.org
time and space. e boy’s perinatal history and early development
were unremarkable. Neurologic examination revealed right-sided
hemiparesis, symmetrically challenged tendon reexes. Walking was
limping. Mental status, cranial nerve assessment, and coordination
were normal. Hereported no sensory decits. EDSS was 3.0. MRI of
the brain revealed three demyelinating lesions in the corona radiata
on the right side, in the centrum semiovale on the le side, and a
parietal subcortical lesion on the le side. All of them displayed
gadolinium enhancement (Figure1). MRI of the spinal cord revealed
one short demyelinating lesion in the lateral cervical medulla with
longitudal length of 0.5 cm, without gadolinium enhancement.
Laboratory studies showed CSF pleocytosis with lymphocyte
predominance. Oligoclonal bands in the CSF and serum were
negative, the method used was Isoelectric Focusing (IEF), followed by
immunoxation. Serum laboratory tests were normal with low
inammatory markers, metabolic and rheumatologic tests were
normal, and microbiological tests of serum and CSF were negative.
Aquaporin-4-IgG and MOG-IgG antibody titers determined using
cell-based assays were negative in CSF and blood serum. e
ophthalmologic examination was normal. ADEM was suspected,
although hedid not meet the International Consensus criteria for
ADEM (24). He was treated with high-dose intravenous
methylprednisolone for 5 days, followed by an oral steroid taper for
4 weeks. He was also treated with intravenous immunoglobulins
(IVIG). At discharge 12 days aer presentation, hestill had some
reduced strength of the right hand, especially of the distal muscles,
and poorer coordination and ne motor skills of the right hand. e
gait was normal, and EDSS at discharge was 2.0. e patient was
admitted to an intensive rehabilitation program. Hecontinued to
receive monthly IVIG applications. e initial management and
treatment of the patient was at the discretion of a pediatrician not
specialized in the treatment of pediatric demyelinating diseases.
Follow-up brain MRI 3 months later showed dissemination of the
lesions in space. Six months aer the right-sided hemiparesis, another
MRI of the brain showed further dissemination of the lesions in space.
By this time, hehad already received 6 monthly IVIG applications,
and the treatment was discontinued. At that time, the patient was
referred to a pediatrician specialized in the treatment of pediatric
demyelinating diseases.
Ten months aer his initial presentation, hepresented with central
facial nerve palsy on the right side and right-sided hemiparesis, EDSS
was 2.0. A brain and spinal cord MRI revealed 5 new lesions, two of
them displayed gadolinium enhancing (Figure2). Laboratory studies
showed mild CSF pleocytosis with decreased glucose in the CSF and
normal protein concentration. Oligoclonal bands in the CSF and
serum were negative, the method used was Isoelectric Focusing (IEF),
followed by immunoxation. MOG-IgG and aquaporin-4-IgG
antibody titers, determined using a cell-based assay in the CSF and
serum, were negative. Serum laboratory tests were normal, and
microbiological tests of the serum and CSF were negative. Metabolic
and rheumatologic testing were normal. Hewas treated again with
high-dose intravenous methylprednisolone for 3 days, followed by a
complete clinical response, EDSS was 0. Monthly IVIG applications
were resumed. e patient was referred to a clinical geneticist to
exclude a possible genetic etiology of his condition. Whole exome
sequencing (WES) followed by targeted gene panel analysis for
neurodegenerative disorders yielded negative results.
Seven months aer the second clinical event, follow-up MRI of
the brain and spinal cord showed multiple new demyelinating
infratentorial lesions. Given that he had two clinical events and
dissemination in time and space on several follow-up MRIs, hemet
the 2017 McDonald’s criteria. Eighteen months aer the rst clinical
episode, aer a thorough discussion with the patient’s parents,
we decided to start rituximab therapy. Before starting rituximab,
weperformed several laboratory tests – complete blood count with
dierential, lymphocyte subpopulations, liver and kidney function
tests, hepatitis B, C and HIV screening, immunoglobulin levels,
tuberculosis tests, VZV serology. Once the safety of this drug for the
patient was assured, treatment with rituximab was started, using
500 mg per meter squared of body surface (maximum dose of
1,000 mg per dose), dosed on days 1 and 15, and then every 6 months
(14). A follow-up MRI 6 months aer rituximab administration
showed regression of the multiple demyelinating lesions and no new
lesions (Figure3).
FIGURE1
(A,B) FLAIR sequence in axial plane at two dierent levels; hyperintense demyelinating lesions (A) periventricular, above the left lateral ventricle (arrow),
(B) in the deep white matter of the right centrum semiovale (arrow); (C) T1 contrast enhancement sequence in axial plane; homogeneous contrast
enhancement of an active lesion (arrow).

Arkar et al. 10.3389/fneur.2024.1359938
Frontiers in Neurology 04 frontiersin.org
e patient was invited for regular follow-up examinations every
6 months in our department, which consisted of a clinical examination,
an MRI and an extended blood laboratory analysis (complete blood
count with dierential, lymphocyte subpopulations, liver and kidney
function tests and electrolyte panel). No serious adverse events (SAEs)
occurred during the follow-up period, but hesuered a local skin
infection with S. aureus, which had to be treated with systemic
antibiotics. At the last clinical examination, 36 months aer initial
presentation, hewas clinically asymptomatic, his EDSS was 0 and his
several follow-up MRIs showed no dissemination in space and time.
Hehad already received three doses of rituximab and had not relapsed
aer starting this therapy (Figure4).
Over the past 3 years, the patient and his parents have shown
exceptional willingness to adhere to the treatment plan, expressing
satisfaction with the medical care received, and gratitude for the
support provided. National insurance fully covered all costs of medical
treatments, ensuring that nancial concerns did not hinder the
patient’s care. Additionally, psychological support services were
provided as part of the standard care. e boy has been able to live a
normal life without neurological decits and can actively participate
in school and sports alongside peers. e boy’s parents expressed keen
interest in sharing their story through this case report to raise
awareness of POMS in the very young, underlining the importance of
early diagnosis and comprehensive care in achieving
favorable outcomes.
Discussion
Pediatric onset multiple sclerosis (POMS) in the very young is a
very rare entity and presents a dicult diagnostic challenge due to
overlapping signs and symptoms with other diseases (2–5, 10, 25).
FIGURE2
Follow-up MRI after 1 year: FLAIR sequence in axial plane at three dierent levels (A–C); progression of the disease; multiple demyelinating lesions in
typical periventricular (arrows) and juxtacortical locations (arrowheads). Among the periventricular lesions, wecan observe a lesion in the splenium of
the corpus callosum on the left side (thick arrow). Other new lesions can also beobserved in the subcortical and deep white matter of the
frontoparietal lobes. The lesions shown in Figure1 have partially regressed (black arrows).
FIGURE3
Follow-up MRI after 2 years: FLAIR sequence in axial plane at the same levels as in Figure2 (A–C); Partial regression of demyelinating lesions after
initiation of therapy.

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Any delay in diagnosis can have a signicant negative impact on the
child’s neurologic outcome.
Our patient rst presented at the age of 4 years with a typical
monofocal nonencephalopathic clinical event (subacute hemiparesis).
is was accompanied by MRI ndings that met the 2017 Revised
McDonald criteria for dissemination in space with more than one
supratentorial lesion and one infratentorial lesion, as well as with
criteria for dissemination in time, as all supratentorial lesions
displayed gadolinium enhancement. Lumbar puncture showed CSF
pleocytosis with negative oligoclonal bands, which is a common
nding in prepubertal children (15).
ADEM was initially suspected in our patient because it is a more
common demyelinating disorder in this age group and a common
misdiagnosis in MS patients with very early-onset (10, 12, 26). Certain
MRI ndings can help dierentiate pediatric patients with MS from
those with ADEM at their rst clinical event (27). e presence of T1
hypointense lesions, T2 periventricular lesions, and brainstem lesions
have been shown to bevery specic and sensitive predictors of MS
diagnosis in pediatric patients with acute demyelinating events
(27, 28).
His subsequent MRIs showed new demyelinating lesions. Ten
months aer his initial presentation, hepresented with his second
clinical event and new demyelinating lesions, which conrmed the
diagnosis of multiple sclerosis (17).
Distinguishing between POMS and other demyelinating diseases
such as MOGAD in very young children is pivotal for implementing
appropriate therapeutic strategies and predicting long-term outcomes.
Recent studies underscore the importance of testing for MOG-IgG
and aquaporin-4-IgG in young pediatric patients presenting with a
demyelinating event (25, 29). Research by Fadda etal. found that
MOG-IgG is detectable even in children who meet the 2017
McDonald diagnostic criteria for MS, highlighting the need to test for
the presence of MOG-IgG at the rst clinical event to avoid
misdiagnosis (25). Furthermore, a study by Yilmaz et al. found a
decrease in POMS in children younger than 12 years, likely attributable
to the recognition of patients with antibody-mediated disease (29).
is evolving understanding emphasizes the importance of
incorporating MOG-IgG and aquaporin-4-IgG testing into the
diagnostic evaluation of pediatric demyelinating diseases.
Currently, only two MS DMTs (ngolimod and teriunomide)
have been tested in large phase III trials and approved by regulatory
agencies for use in POMS (30). ere is growing evidence that patients
with POMS need early treatment with highly eective disease-
modifying therapy (DMT) to prevent signicant long-term disability
(31, 32). However, an unanswered question is the use of newer DMTs
in patients younger than 10 years of age. In recent years, only a few
case reports and case series have been published on children with
prepubertal MS (8, 13), making it dicult to decide on the most
appropriate treatment in this age group. Although there are some
treatment recommendations for prepubertal children (14), treatment
decisions still depend largely on local clinical practice. Our decision
to use rituximab was guided by the recommendations in the review
by McGinley and Rossman (14). Additionally, our decision was
inuenced by the limited experience with other DMTs in prepubertal
children, whereas rituximab is a well-established and time-tested
therapy that is frequently used in pediatric rheumatologic diseases,
where it has demonstrated a favorable safety prole. Wethoroughly
discussed all possible treatment options and associated risks with the
patient’s parents and nally obtained consent for treatment with
rituximab. In our patient, treatment with rituximab resulted in good
disease control and an excellent outcome. During the follow-up
period, heexperienced no further relapses or radiological progression
of the disease and no serious adverse events.
We believe that our experience is valuable and will contribute to
a better understanding of disease progression in patients with very
early-onset MS and to the clinical evaluation, management, and
treatment of these patients. Further prospective studies are needed to
decide on the best therapeutic approach in such young children.
In conclusion, early recognition and treatment are benecial for
favorable outcome in very early onset POMS patients. Further
observational and prospective studies in this patient population are
warranted to provide new recommendations for the best
treatment options.
Data availability statement
e original contributions presented in the study are included in
the article/supplementary material, further inquiries can bedirected
to the corresponding author.
Ethics statement
e studies involving humans were approved by National
Medical Ethics Committee of the Republic of Slovenia. e studies
were conducted in accordance with the local legislation and
institutional requirements. Written informed consent for
participation was not required from the participants or the
participants’ legal guardians/next of kin in accordance with the
national legislation and institutional requirements. Written informed
consent was obtained from the minor(s)’ legal guardian/next of kin
for the publication of any potentially identiable images or data
included in this article.
FIGURE4
Case timeline.

Arkar et al. 10.3389/fneur.2024.1359938
Frontiers in Neurology 06 frontiersin.org
Author contributions
UA: Writing – original dra, Conceptualization, Data curation,
Investigation, Methodology. TVV: Writing – original dra, Data curation,
Investigation, Visualization. DO: Writing – review & editing, Resources,
Supervision. MPB: Writing – review & editing, Conceptualization,
Supervision. NB: Writing – original dra, Writing – review & editing,
Conceptualization, Data curation, Formal analysis, Funding acquisition,
Investigation, Methodology, Supervision, Validation.
Funding
e author(s) declare that no nancial support was received for
the research, authorship, and/or publication of this article.
Conflict of interest
e authors declare that the research was conducted in the
absence of any commercial or nancial relationships that could
beconstrued as a potential conict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors
and do not necessarily represent those of their aliated
organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or claim
that may be made by its manufacturer, is not guaranteed or endorsed
by the publisher.
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