Hello, and welcome to Say Hello to Balos, Inpatient Rehabilitation of Balos Disease. My name is George Schilling, and I am a third-year PM&R resident at East Carolina University. Balos concentric sclerosis is a rare subtype of multiple sclerosis and is named after Dr. Joseph Balos, a Hungarian physician first defined in 1928. It has a unique pathology that we'll see soon. Our patient was a 23-year-old female with a one-year history of Balos disease. She was on Tecfidera to manage her relapsing multiple sclerosis, but was often noncompliant. Our patient developed five days of right-sided hemiparesis, confusion, and gait disturbances. MRI showed a new enhancing lesion in the right brachial pontus, and she was started on a course of IV steroids with some relief in her symptoms. She was admitted to inpatient rehab, where her dizziness and gait disturbances improved with scopolamine, meclizine, diazepam, neuromuscular re-education, and visual perceptual retraining. Image A is an axial T2 flare MRI of the brain from her admission showing the new lesion with concentric layers in the right brachial pontus. Image B is a sagittal T1 MRI of her brain from her previous admission, which shows a more well-defined lesion in the right cerebral hemisphere. And Image C is from Dr. Balos' original case. There have been other images to show progression of larger lesions to over 10 layers. Balos disease, as we mentioned before, is a rare subtype of MS characterized by concentric layers of demyelinated tissue on imaging studies. Although the pathophysiology is unknown, it is theorized that this pattern is due to physiological hypoxia causing the dark demyelinated tissue, which leads to expression of protective stress proteins at the border, and finally leading to the myelinated white layer. Subsequent attacks lead to this expression and counterexpression and add another layer of preserved tissue forming the rings seen on imaging. Balos disease also distinguishes itself from MS by often being rapidly progressive rather than waxing and waning. Although there have been more recent reports of prolonged survival or spontaneous remission. As shown in this case, patients with this MS subtype can benefit from intensive inpatient rehabilitation. The patient currently is doing well and is more compliant with her disease modifying agents. Again, my name is George Schilling, and thank you for joining us.

Balos concentric sclerosis

rare subtype

multiple sclerosis

concentric layers

demyelinated tissue