Multiple Sclerosis

Young adult presents with acute onset weakness. Reports associated fatigue, weakness, dizziness, changes in vision, discoordination/gait disturbances, and paresthesias. Experienced a similar event previously that resolved spontaneously. Denies h/o seizures, aphasia. Nystagmus, red color desaturation, Lhermitte sign, decreased strength, decreased sensation, spasticity, and gait disturbance noted on exam.

• Labs

  • Obtain CBC, ESR, ANA, vitamin B12 level, RPR

  • Consider obtaining HIV test, Lyme titre, ACE level

  • CSF analysis shows IgG oligoclonal bands

• MRI shows periventricular white matter lesions including Dawson’s fingers

• Treatment: Refer to neurology

  • Start methylprednisolone 1000 mg qd x5 days; no oral taper necessary

  • Start glatiramer 20 mg subcutaneous injection daily

  • Spasticity and/or neuropathic pain: Start baclofen 5 mg TID and increase by 5 mg per dose q3 days; max daily dose 80 mg

• Counseling

  • Pt counseled that fatigue, spasticity, neurogenic bladder, and/or sexual dysfunction may develop and/or worsen as the condition progresses

  • Pt counseled that family members may wish to start 25-hydroxyvitamin D supplementation to decrease risk

Notes

• Most common permanently disabling CNS disorder in young adults

• More common at higher latitudes

• Diagnosis requires two neurologic deficits separated in time and space

  • Lhermitte sign: Neck flexion produces electrical sensation that radiates down spine

  • ACE level is used to r/o sarcoidosis

  • Oligoclonal IgG bands is suggestive, but not diagnostic

  • Dawson’s fingers: White matter lesions that radiate from the lateral ventricles into the corpus callosum

• DMARDs

  • Should be started shortly after diagnosis and reduce disease progression

  • There are multiple options; glatiramer and its dosing is given as one example