title: An uncommon first manifestation of multiple sclerosis: Tako-Tsubo cardiomyopathy.
abstract: Clinically isolated syndromes affecting the brainstem may present with rare manifestations such as neurogenic pulmonary oedema (NPO).
  
  
  
  We present the case of a 23 year-old man with NPO caused by Tako-Tsubo cardiomyopathy (TTC) as a first manifestation of multiple sclerosis (MS).
  
  
  
  A brain magnetic resonance imaging scan at admission showed multiple supra and infratentorial white matter inflammatory demyelinating lesions. This examination was repeated 2 and 4 weeks after symptoms onset and active lesions showing contrast uptake were identified, two of them involving the pons and the medulla oblongata, probably affecting the solitary tract nucleus. Cerebrospinal fluid oligoclonal bands were detected. The patient was treated with a 3-day course of 1g intravenous methylprednisolone presenting a significant and progressive improvement. The proposed underlying physiopathology is an excessive secretion of catecholamines resulting in myocardial stunning and ventricular failure. Two months later he developed optic neuritis and disease-modifying treatment was initiated.
  
  
  
  Clinicians should consider a possible neurological origin of TTC, and according to the clinical characteristics of the patient, MS may be suspected.
authors.affiliation: Department of Neurology/Neuroimmunology, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain lmidaglia@cem-cat.org.
authors.forename: Luciana
authors.initials: L
authors.lastname: Midaglia
authors.affiliation: Department of Neurology, Hospital San Pedro de Logroño, La Rioja, Spain.
authors.forename: Jesús M
authors.initials: JM
authors.lastname: Juega Mariño
authors.affiliation: Department of Neurology/Neuroimmunology, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Jaume
authors.initials: J
authors.lastname: Sastre-Garriga
authors.affiliation: Section of Neuroradiology, Department of Radiology (IDI), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Alex
authors.initials: A
authors.lastname: Rovira
authors.affiliation: Department of Neurology/Neuroimmunology, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Angela
authors.initials: A
authors.lastname: Vidal-Jordana
authors.affiliation: Department of Neurology, Hospital San Pedro de Logroño, La Rioja, Spain.
authors.forename: María A
authors.initials: MA
authors.lastname: López-Pérez
authors.affiliation: Department of Neurology, Hospital San Pedro de Logroño, La Rioja, Spain.
authors.forename: María E
authors.initials: ME
authors.lastname: Marzo-Sola
authors.affiliation: Department of Cardiology, Hospital San Pedro de Logroño, La Rioja, Spain.
authors.forename: Fausto
authors.initials: F
authors.lastname: Librada Escribano
authors.affiliation: Department of Neurology/Neuroimmunology, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Xavier
authors.initials: X
authors.lastname: Montalban
mesh_terms: D000328:Adult; D006801:Humans; D008297:Male; D009103:Multiple Sclerosis / Q000150:complications* / Q000175:diagnosis; D011654:Pulmonary Edema / Q000175:diagnosis / Q000209:etiology; D054549:Takotsubo Cardiomyopathy / Q000175:diagnosis / Q000209:etiology*; D055815:Young Adult
keywords: Tako-Tsubo cardiomyopathy; autonomic nervous system; clinically isolated syndrome; multiple sclerosis; solitary tract nucleus