Neurology · Year 3 · from Neurology

Case 1: Relapsing-Remitting Multiple Sclerosis

Patient Demographics

  • Age: 28 years
  • Sex: Female
  • Occupation: Marketing coordinator

Chief Complaint

"I can't see out of my right eye and my legs feel numb."

History of Present Illness

The patient developed pain behind her right eye 5 days ago that worsened with eye movement. Over the following 2-3 days, she noticed progressive vision loss in that eye, now describing it as "looking through frosted glass." She also reports that her legs have felt "pins and needles" and heavy for the past week, making it difficult to climb stairs. On further questioning, she recalls an episode 2 years ago when she had numbness and tingling from her feet up to her waist that resolved spontaneously over several weeks. She also mentions that hot showers seem to make her vision worse (Uhthoff phenomenon). No recent infections, vaccinations, or travel.

Neurological Examination Findings

Mental Status:

  • Alert, oriented, appropriate
  • Mildly anxious about symptoms

Cranial Nerves:

  • CN II (Right):
  • Visual acuity: 20/200 (reduced from baseline 20/20)
  • Color vision: Unable to identify red (dyschromatopsia)
  • Relative afferent pupillary defect (RAPD) present - Marcus Gunn pupil
  • Visual field: Central scotoma
  • Fundoscopy: Optic disc mildly swollen (papillitis) vs normal (retrobulbar neuritis)
  • CN II (Left): Visual acuity 20/20, normal
  • Extraocular movements: Pain with right eye movement, otherwise intact

Motor Examination:

  • Upper extremities: 5/5 bilateral
  • Lower extremities: 4+/5 hip flexion bilaterally, 4+/5 knee flexion
  • Increased tone in both legs (mild spasticity)

Sensory Examination:

  • Decreased sensation to pinprick and light touch below T10 level bilaterally
  • Vibration sense reduced at ankles
  • Lhermitte sign positive - electric shock sensation down spine with neck flexion

Reflexes:

  • Upper extremities: 2+ symmetric
  • Lower extremities: 3+ bilateral (hyperreflexia)
  • Bilateral Babinski signs positive

Coordination:

  • Finger-to-nose: Normal
  • Heel-to-shin: Mildly impaired (sensory ataxia)

Gait:

  • Mildly spastic, circumduction of legs

McDonald Criteria Assessment

2017 McDonald Criteria for MS:

  1. Dissemination in Space (DIS): Lesions in ≥2 of 4 CNS areas:
  • Periventricular (YES - see MRI)
  • Cortical/juxtacortical (YES)
  • Infratentorial (YES)
  • Spinal cord (YES - clinical myelopathy)
  1. Dissemination in Time (DIT): Can demonstrate by:
  • New T2 or enhancing lesion on follow-up MRI, OR
  • Simultaneous presence of enhancing and non-enhancing lesions, OR
  • History of prior relapse (YES - episode 2 years ago)

Neuro Workup

  • MRI Brain with and without contrast:
  • Multiple periventricular T2/FLAIR hyperintense lesions, ovoid, perpendicular to ventricles ("Dawson's fingers")
  • Several lesions enhance with gadolinium (active/acute)
  • Several non-enhancing lesions (chronic)
  • Right optic nerve enhancement (optic neuritis)
  • MRI Spine with contrast:
  • T2 hyperintense lesion at T8 level, partial spinal cord involvement
  • Enhancement present
  • Lumbar Puncture:
  • Opening pressure: 14 cm H2O (normal)
  • WBC: 8 (mildly elevated lymphocytes)
  • Protein: 55 (mildly elevated)
  • Glucose: 65 (normal)
  • Oligoclonal bands: Present in CSF, absent in serum (95% MS)
  • IgG index: Elevated (0.85; normal <0.7)
  • Visual Evoked Potentials: Prolonged P100 latency in right eye
  • Labs: B12, TSH, NMO-IgG (aquaporin-4), MOG antibody - all negative

Diagnosis

Relapsing-Remitting Multiple Sclerosis (RRMS) with acute relapse

  • Current attack: Optic neuritis + myelitis
  • Prior attack: Transverse myelitis (2 years ago)
  • McDonald criteria fulfilled (DIS + DIT)

Management

Acute Relapse Treatment:

  1. IV methylprednisolone 1 g daily for 3-5 days
  • Shortens duration of relapse
  • Does not affect long-term outcomes
  1. Oral prednisone taper optional
  2. If no response: Plasmapheresis (PLEX) for severe relapses

Disease-Modifying Therapy (DMT):

  1. Initiate DMT - proven to reduce relapse rate and slow disability accumulation
  2. First-line options:
  • High-efficacy: Ocrelizumab (anti-CD20), natalizumab (anti-VLA-4), ofatumumab
  • Moderate efficacy: Dimethyl fumarate, fingolimod, teriflunomide
  • Injectable: Interferon beta, glatiramer acetate (less commonly used now)
  1. Choice for this patient: Ocrelizumab or natalizumab (high disease activity - optic neuritis + myelitis)
  2. Pre-DMT workup: JC virus antibody, hepatitis B/C, TB, varicella immunity, CBC, LFTs

Symptomatic Management:

  1. Fatigue: Amantadine, modafinil, or amphetamine-based stimulants
  2. Spasticity: Baclofen, tizanidine, physical therapy
  3. Bladder dysfunction: Anticholinergics, intermittent catheterization
  4. Depression: SSRIs
  5. Neuropathic pain: Gabapentin, pregabalin

Rehabilitation:

  1. Physical therapy for gait and balance
  2. Occupational therapy for energy conservation

Counseling:

  1. Vitamin D supplementation (maintain levels >30-40 ng/mL)
  2. Smoking cessation (smoking worsens MS)
  3. Regular exercise
  4. Reproductive planning - discuss DMT safety in pregnancy

Clinical Image

Image Description: Axial FLAIR MRI showing multiple periventricular white matter lesions perpendicular to the lateral ventricles (Dawson's fingers), characteristic of multiple sclerosis.

Attribution: Image from Radiopaedia.org, Case courtesy of Dr. Frank Gaillard. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/multiple-sclerosis-15

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