Yamada et al. Journal of Medical Case Reports 2012, 6:104 http://www.jmedicalcasereports.com/content/6/1/104 from those of a brain tumor [12]. Recently, some suc- cessful challenges to diagnose tMS by using MRS and PET, without biopsy, have been reported [5-7], and care- ful follow-up by serial MRI with or without steroid treatment is usually sufficient to establish the diagnosis. In general, tMS lesions respond well to steroids and no radiological evidence of new lesions is identified after the treatment in most patients [13]. Although the clini- cal course of tMS is various with acute onset, the prog- nosis of tMS usually does not depend on the clinical presentation [3]. However, in some atypical cases, the radiological diagnosis is no more than speculative if his- tological diagnosis is not obtained. Butteriss and collea- gues [14] reported an interesting case of oligodendroglioma in MS that was diagnosed by surgical removal of the lesion but that had been considered to be tMS on pre-operative MRI. In our case, fulminant deterioration of the clinical symptoms and rapid enlar- gement of the lesions on MRI in spite of steroid pulse therapy confounded the diagnosis of tMS. When mono- clonal bands are not detected in CSF and radiological examinations cannot completely rule out a malignant brain tumor, an early decision to perform a biopsy is required. Once fulminant deterioration of clinical signs and symptoms occurs in a patient with tMS, the neuro- logical deficits can be irreversible. Conclusions To diagnose tMS without histological investigation is an initial approach to the disease. However, early biopsy should not be delayed if radiological examination failed to confirm the diagnosis. Consent Written informed consent was obtained from the patient for publication of this manuscript and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Abbreviations CD: cluster of differentiation; CSF: cerebrospinal fluid; MRC: Medical Research Council; MRS: magnetic resonance spectroscopy; MRI: magnetic resonance imaging; PET: positron emission tomography; tMS: tumefactive multiple sclerosis. Author details 1Department of Neurosurgery, Teikyo University Chiba Medical Center, 3426- 3 Anesaki, Ichihara-city, Chiba-prefecture 299-0111, Japan. 2Department of Pathology, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara- city, Chiba-prefecture 299-0111, Japan. Authors’ contributions SY was a major contributor in writing the manuscript. SMY performed surgery, analyzed the data, and revised the manuscript. HN and MM managed the patient, planned imaging studies, and analyzed the data. 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