Case presentation
A forty-four years old Female patient with co-morbid illnesses. She was presented two years ago by acute onset severe vertigo lasted for two days. This vertigo was related to position increased in lying on either side associated with nausea and recurrent vomiting and inability to walk. The patient condition was not preceded by viral infection or ear problem. On examination the patient was conscious, alert, oriented to date time and persons. There was first degree bilateral horizontal nystagmus with intact motor, normal planter response, intact sensation and intact cerebellar examination at that time. The ENT examination was normal (no middle ear problems, viral infection or vesicles), but there was positive Dix Hallpike manoeuvre. Patient was admitted combined neurology and ENT for further evaluation and for MRI brain. The MRI brain result showed multiple demyelinating patches corresponding to multiple sclerosis diagnosis (Figure 1a ,1b , 1c). We started her on pulse steroid therapy for five days with marked improvement. We referred her for multiple sclerosis specialized centre where they confirm diagnosis via CSF analysis (oligoclonal bands and IgG index). Patient was started fingolimod 0.5 mg orally once daily.

Methods

This review is performed and reported according to meta-analysis (PRISMA) guidelines (5).

Literature search strategy

We systematically searched data bases: PubMed, Scopus, Web of Science and Chochrane. The following search term was used for data base search: (“Benign Paroxysmal Positional Vertigo” OR “Benign positional vertigo” OR “peripheral vertigo” OR “acute vestibular syndrome” OR “acute vestibulopathy” OR “Familial Vestibulopathy” OR “Benign Recurrent Vertigos” OR BPPV) AND (“Multiple sclerosis” OR “disseminated sclerosis” OR MS). Last literature search was done on 27th, October 2021.

Eligibility criteria and study selection

To include studies in our systematic review, they must contain original data about BPPV as first presentation and multiple sclerosis.
And because the data available on his topic is very rare, we decided to include all studies designs including case reports except litter to editor, reviews, and comments. Study screening and study selection were performed by two independent researchers. (Figure 2)

Results

From 339 studies screened, only four studies met the eligibility criteria for our systematic review. The four studies were case reports with 32 cases as follows: (25, 5, 1, 1),(Frohman 2000, Thomas 2016, Musat 2020, Yoosefinejad 2015) respectively (6-8).
Demographic characteristics and clinical data were extracted as in (Table 1). Age ranges from 31 to 44 years with 19 female cases and 8 male cases. 2 cases were initially diagnosed as BPPV and then found MS was seen on MRI as white patches. In those two cases, Epley and deep head hanging maneuver didn’t relieve vertigo but with steroid use in the second case (Musat 2020) was relived. In (Yoosefinejad 2015) the case was initially diagnosed with MS 6 years before developing BPPV which was diagnosed by clinical presentation then they confirmed the diagnoses after Semont and Epley maneuvers used and significantly relieved the BPPV.

Discussion

Benign paroxysmal positional vertigo (BPPV) is defined as a disease of the inner ear characterized by repeated episodes of positional vertigo. BPPV could be clinically diagnosis by elicitation of nystagmus and vertigo on provoking maneuvers for BPPV (9). Although provoking maneuvers are very useful, minute changes in their findings should raise suspicion of other central causes as it could be easily mixed with central positional vertigo (CPV). CPV can be, CPN is caused by cerebellar and/or brainstem dysfunction and can mimic BPPV (10).
For patients with atypical presentation of BPPV, the physician should consider further investigation with audiometry, vestibular function testing, and neuroimaging.
Atypical BPPV presentation could be: Vertigo that lasts longer than one minute, associated hearing loss, Associated neurological symptoms like gait disturbances or previous history of neurological disorders or tumors. Failure to respond to canalith repositioning maneuvers or vestibular rehabilitation therapy.