Case Report: Use of Fingolimod in an Hispanic MS Pediatric Patient

Background: A 10 year old girl presented to a community hospital emergency room with dizziness, dysconjugate gaze, bilateral nystagmus, R hemifacial paralysis and bilateral blurry vision. The patient denied loss of vision, consciousness, fecal nor urine incontinence. She was initially diagnosed with Acute Demyelinating Encephalomalacia (ADEM) and treated with 5 day course of IV steroids. She had complete resolution of all her symptoms at discharge.

Her follow up consisted of serial MRIs every 6 months. At 2 years post hospitalization, she developed 3 new GAD enhancing lesions. She did not have new or recurring symptoms. Her diagnosis was changed from ADEM to Multiple Sclerosis (MS). Interferon beta 1-a at a 1 dose/week regimen was started and instructed to have an MRI every 6 months. The patient continued treatment for 6 more months when 2 more GAD enhancing lesions developed without any new nor recurring symptoms. 

She continued her care with a neurologist specialized in MS for a second opinion of her treatment. The decision was made to try Fingolimod (FTY) 0.5 mg at every other day dose regimen. Her EDSS score at presentation was 1.5 because an increase knee reflex and positive Romberg.

The patient has been followed for 2 years. She has reported occassional headaches when she started the medication, but the headaches have since subsided. Her lab work (CBC, CMP, UA, TSH,) have consistently been unremarkable and within normal limits. She has had 3 MRI since starting FTY. Her MRIs do not show any new GAD enhancing lesions and previous T2/Flair lesions have decreased in signal intensity correlating with decrease in inflammation. At 2 year follow up, her EDSS score has decreased to 1.

Conclusions: FTY can be considered as an option when treating pediatric MS patients at a 0.5mg qod dosing. This patient’s case is interesting considering she never presented with a recurrent or new symptom when she developed positive GAD enhancing lesions. Her MS can be considered Clinically Isolated Syndrome or CIS. She would specifically be labeled as Pediatric CIS or PCIS. In our estimation, FTY can reduce disease activity and protect pediatric MS patients. The authors emphasize close patient follow up and lab work (CBC, CMP, UA, TSH) when treating pediatric MS patients with FTY.