Neuroscience · Year 2 · from Neuroscience
Case 2: Multiple Sclerosis - Relapsing-Remitting
Patient Presentation
Demographics: 28-year-old female
Chief Complaint: Right eye vision loss and leg weakness
History of Present Illness: The patient developed pain with eye movement in her right eye 5 days ago, followed by progressive vision loss over 3 days. She describes the vision as "looking through wax paper." Her color vision is particularly affected - reds look "washed out." She now recalls that 2 years ago, she had an episode of numbness and tingling in her legs lasting 3 weeks, which she attributed to stress and never sought medical attention for.
Physical Examination:
- Vital signs: Normal
- General: Healthy-appearing young woman
- Neurological:
- Mental status: Normal
- Cranial nerves:
- Visual acuity: Right eye 20/200 (left eye 20/20)
- Color vision: Cannot identify Ishihara plates with right eye
- Pupils: Right relative afferent pupillary defect (RAPD) - when light swings to right eye, both pupils dilate (Marcus Gunn pupil)
- Fundoscopy: Right optic disc slightly swollen (papillitis)
- Other cranial nerves normal
- Motor: 5/5 throughout
- Sensory: Decreased vibration sense at toes bilaterally
- Reflexes: 3+ throughout; bilateral Babinski signs
- Coordination: Normal
- Gait: Normal
Key Findings:
- Optic neuritis (right)
- Prior episode of transverse myelitis (history of leg numbness)
- Signs of prior spinal cord involvement (hyperreflexia, Babinski)
- = Dissemination in space AND time
Workup:
- MRI brain with and without contrast: Multiple ovoid T2/FLAIR hyperintense lesions in periventricular white matter oriented perpendicular to the ventricles ("Dawson's fingers"); several juxtacortical lesions; one enhancing lesion (active); one infratentorial lesion
- MRI spine: Two non-enhancing T2 lesions in cervical cord
- MRI orbits: Right optic nerve enhancement and swelling
- Lumbar puncture: Oligoclonal bands present in CSF (absent in serum); elevated IgG index; mild lymphocytic pleocytosis (12 cells)
Diagnosis: Multiple sclerosis, relapsing-remitting (McDonald 2017 criteria satisfied)
Treatment:
Acute Optic Neuritis:
- IV methylprednisolone 1 gram daily for 3 days
- Oral prednisone taper over 2 weeks
Disease-Modifying Therapy:
- Discussed options: moderate efficacy (interferons, glatiramer) vs high efficacy (ocrelizumab, natalizumab)
- Started ocrelizumab (anti-CD20) given multiple lesions indicating active disease
- Baseline JCV antibody: Negative
- Hepatitis B screening: Negative
Other:
- Vitamin D supplementation (2000 IU daily)
- Smoking cessation counseling (she is a social smoker)
- Discussed pregnancy planning (ocrelizumab has washout period)
Clinical Course: Visual acuity improved to 20/30 at 6 weeks; color vision partially recovered. No new relapses occurred on ocrelizumab over 1 year. Surveillance MRI showed no new or enhancing lesions. She remained fully functional, working full-time as an accountant.
Clinical Pearl: Multiple sclerosis diagnosis requires dissemination in space (lesions in multiple CNS locations) and time (new activity over time or simultaneous enhancing and non-enhancing lesions). Optic neuritis is often the presenting manifestation - the triad of painful eye movement, vision loss, and RAPD is classic. Oligoclonal bands in CSF are present in >95% of MS patients. Early treatment with highly effective disease-modifying therapy prevents accumulation of disability. Dawson's fingers (periventricular lesions perpendicular to ventricles) are characteristic of MS and reflect perivenular inflammation.