Dear Editor,
We present a rare case of coexisting mesial temporal lobe sclerosis (MTLS) and systemic sclerosis (SSc), presenting with manifestations as cognitive decline, seizures, and psychiatric symptoms in the form of sadness, mood, irritability, and decreased interaction. This case highlights the diagnostic and therapeutic challenges faced by the overlapping of neurological, autoimmune, and psychiatric conditions.
A 30-year-old right-handed female school teacher presented with a history of progressive cognitive decline, episodic forgetfulness, restlessness, and palpitations for four months. She reported frequent headaches, described as dull and bilateral, without any specific aggravating factor. In October 2023, she experienced two episodes of generalized tonic-clonic seizures, each episode lasting 2–3 minutes, characterized by involuntary jerking of all four limbs, uprolling of eyeballs, and post-ictal confusion. There was no history of tongue biting or urinary incontinence. Initial treatment with levetiracetam controlled the seizures, but no improvement in the cognitive symptoms. Psychiatric evaluation revealed mood lability, social withdrawal, and paranoid ideation. Neurological examination showed severe cognitive impairment Mini Mental Status Examination (MMSE: 16/30), Montreal Cognitive Assessment (MoCA): 16/30), and impaired recall. MRI Brain (T2/FLAIR) revealed bilateral hippocampal hyperintensities with volume loss consistent with MTLS, autoimmune panel, that is, ANA blot: Positive for Scl-70 (anti-topoisomerase I), confirming systemic sclerosis SSc.
The coexistence of MTLS and SSc is exceptionally rare, which raises questions about shared pathophysiology.[1,2,3] Potential mechanisms include: Vascular Dysfunction: SSc-related microvascular ischemic changes can contribute to hippocampal damage;[1] Autoimmune Inflammation: Scl-70 antibodies might cross-react with neuronal antigens, resulting in hippocampal sclerosis; and Psychosocial Stressors:[2] Chronic psychological stressors worsen cognitive deficits via glucocorticoid-mediated hippocampal atrophy.[3]
Management involved a multidisciplinary team (neurology, rheumatology, and psychiatry). The patient was started on Desvenlafaxine for depressive symptoms, risperidone for irritable behavior, oxcarbazepine (seizures/mood stabilization), and for forgetfulness, donepezil, memantine (5 + 5), and prednisolone. Over 3 weeks, her symptoms improved, underscoring the importance of an integrated multidisciplinary approach.
This case highlights the importance of considering autoimmune pathology in psychiatric and cognitive presentations. Future research should explore neuro-autoimmune interactions and the role of immunomodulation in such comorbidities.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Authors contribution
Concept, design: RB, YV, SG, SSB; Data acquisition & manuscript preparation: YV; Manuscript review and editing: RB, SG, SSB.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
REFERENCES
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