Case report
Recurrent atrial fibrillation after pulse corticosteroid treatment for a relapse of multiple sclerosis

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Highlights

Abstract

Standard therapy for a relapse of multiple sclerosis is a high dose pulse corticosteroid therapy. Cardiovascular adverse events ranging from palpitations to serious arrhythmias like atrial fibrillation and ventricular tachycardia have been associated with this treatment. The underlying mechanism behind the development of atrial fibrillation and treatment of multiple sclerosis relapse with steroids is still unclear. In this case, a 27-year-old male with multiple sclerosis is presented who developed atrial fibrillation on two occasions following two consecutive treatments with high dose methylprednisolone for the treatment of multiple sclerosis relapse. Extensive work-up revealed mild sympathetic autonomic system dysfunction. Based on this case and previous studies, we propose that a disturbed function of the autonomic system increases the risk of atrial fibrillation and/or other arrhythmias in people with multiple sclerosis.

Introduction

Clinical manifestations of multiple sclerosis (MS) may be various and they mostly depend on the location of the demyelinating lesions in the brain and the spinal cord. Although rare, cardiopulmonary disturbances such as neurogenic pulmonary edema or neurogenic stunned myocardium have been associated with demyelinating lesions in the brainstem (Valencia-Sanchez et al., 2019). Electrocardiographic changes that can lead to arrhythmia have been reported in people with MS (pwMS) (Razazian et al., 2014) and the risk for developing rhythm abnormalities differs for the type of arrhythmia and depends on the therapies the patient is receiving. For example, the risk for atrial fibrillation (AF) is overall decreased in MS (Roshanisefat et al., 2014), while the standard relapse therapy with corticosteroids increases the risk of AF immediately after the therapy. The most frequent side effects of a high dose pulse corticosteroid therapy are change in taste (61%), facial flushing (61%), insomnia (44%), agitation (36%) and behavioral changes (36%) (Jongen et al., 2016). Alongside these, the cardiovascular system adverse events have been described in pwMS treated with high dose corticosteroids, ranging from palpitations to more severe adverse events like AF (1.8%) or ventricular tachycardia (0.6%) (Jongen et al., 2016; Vasheghani-Farahani et al., 2011). However, the mechanism of AF after treatment with corticosteroids in MS is unclear.

We report a case of recurrent paroxysmal AF following a high dose corticosteroid treatment in a pwMS with a sympathetic autonomic dysfunction.

Section snippets

Case report

A 27-year-old male presented with blurry vision and paresthesiae of the right extremities in February 2011. Besides having congenital pendular nystagmus, the rest of the medical history was unremarkable. Multiple periventricular and juxtacortical demyelinating lesions were present on the brain MRI, with one enhancing supratentorial lesion after Gadolinium application. Oligoclonal IgG bands were positive in the cerebrospinal fluid. Following high dose pulse methylprednisolone therapy, he fully

Discussion

The exact underlying mechanisms of arrhythmias following high doses of corticosteroids are unclear, but several hypotheses have been suggested.

The first one includes electrolytes changes associated with corticosteroids treatment. Fujimoto et al. observed a small but significant increase in urinary potassium loss during a pulse therapy with methylprednisolone (Fujimoto et al., 1990). Methylprednisolone may mediate a potassium efflux via a direct effect on the myocardial cell membrane and

Financial and competing interest

None of the authors have relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.

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