{
  "abstract": "Tumefactive multiple sclerosis is a rare variant of multiple sclerosis (MS) that poses a diagnostic challenge due to its resemblance to central nervous system (CNS) neoplasms on MRI. Tumefactive demyelinating lesions (TDL) occur in 1–3/1000 MS cases, typically with atypical clinical presentations. We would like to present a case of a 43-year-old man with TDL in the context of extensive previous immunosuppression for treatment resistant psoriatic arthritis. At the time of presentation, he was managed on sekukinumab, leflunomide, methotrexate and oral prednisolone. He had previously been managed with multiple anti-TNFa agents including adalimumab. He presented with severe headaches, right hemianopia and left leg numbness, with some response to IV methylprednisolone. Physical examination showed right-sided hemianopia and decreased sensation to pin prick in his left lower leg. MRI brain demonstrated a large left parietal lesion with incomplete peripheral FLAIR enhancement and further right sided lesions favoured to be demyelinating. His initial cerebrospinal fluid (CSF) analysis demonstrated no lymphocytes, normal glucose and protein of 0.47 g/L and matched oligoclonal bands. Viral PCR including JC virus PCR in CSF was negative and anti-MOG antibodies were also negative. Repeat MRI two weeks later demonstrated worsening oedema and increased FLAIR hyperintensities. A brain biopsy was considered but given the most likely aetiology to be tumefactive demyelination, he was urgently commenced on natalizumab and IV methylprednisolone, whilst reducing his pre-existing immunosuppression (ceasing methotrexate, leflunomide and oral prednisolone). A repeat MRI brain demonstrated significant improvement. The patient remains clinically stable.",
  "authors": [
    {
      "affiliations": [
        "Department of Neuroscience, Alfred Health, Melbourne, VIC, Australia"
      ],
      "name": "Sarah E Butler"
    },
    {
      "affiliations": [
        "Department of Neuroscience, Alfred Health, Melbourne, VIC, Australia"
      ],
      "name": "Tracie Tan"
    },
    {
      "affiliations": [
        "Monash University, Melbourne, VIC, Australia"
      ],
      "name": "Kate Franklyn"
    },
    {
      "affiliations": [
        "Department of Neuroscience, Alfred Health, Melbourne, VIC, Australia",
        "Neuroimmunology, Neuroinflammation and Neurooncology (N^3) Lab, Monash University, Melbourne, VIC, Australia"
      ],
      "name": "Mastura Monif"
    }
  ],
  "title": "3474 Tumefactive multiple sclerosis with previous extensive anti-TNF-a usage",
  "uid": "6800e695-69ac-5475-9cb4-bc23fba9b8f5"
}