Case 1

Page created on April 4, 2021. Last updated on April 7, 2021 at 21:23

Anna, a 30-year-old woman with fair skin, presents to you with a 14-day history of visual loss on the left eye, diplopia, bladder incontinence, and numbness of the left arm. She has had a similar episode a year ago, at which time she had the same visual problems, but at that time she also had some problems walking. You perform a neurological examination and find decreased sensation on the left arm, as well as horizontal nystagmus of her right eye when abducted.

You suspect multiple sclerosis but should rule out neuromyelitis optica. To exclude neuromyelitis optica, you measure anti-AQP4 in the serum, which comes back negative. You refer her to an MRI of the head with and without contrast, which shows only inconclusive findings. Nevertheless, we have evidence of dissemination in time because this is her second episode, and we have evidence of dissemination in space because her symptoms point to her having lesions in both the optic nerve and spinal cord (bladder problems, arm numbness).

With this information you diagnose her with multiple sclerosis according to the McDonald criteria. You explain to Anna that multiple sclerosis is a chronic demyelinating disorder that she must live with and which will progressively worsen, but treatment can slow the progression. You prescribe her disease-modifying therapy to slow the progression, and methylprednisolone for this acute attack, and instruct her to return to you in case she experiences further episodes so she can receive methylprednisolone.

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