A 30-year-old woman presents to your office with a 2-day history of progressive, unilateral arm (proximal and distal) numbness without weakness. She has been diagnosed with fibromyalgia in the past. She is taking fluoxetine for depression and has a history of previous hospitalizations for depression.
1, What will be your next step in management?
Answer: Get additional history; ask about previous similar episodes or other neurological concerns With a progressive neurological deficit, the first step in the workup is to further explore
the history. Frequently, patients will not mention previous neurological symptoms because the symptoms, not are vague.
When you ask about previous spells, she notes that she had an episode of left leg numbness that lasted about 1-week several years ago, but she thought nothing of it as it was mild. Six months ago, she had a 3-day visual disturbance in her right eye, during which she found it difficult to read and focus on objects; no blind spot was noticed. However, she had pain in the eye, especially when moving it.
2. What is the most likely diagnosis based on the history given?
Answer: Multiple Sclerosis would be the most likely diagnosis based on the history related above.
Clinical features: MS most commonly presents in women 20–35 years old and in men 35–45 years old. It is almost five times more prevalent among women than among men and is more common in the Caucasian population.
MS is a central nervous system demyelinating disease that is thought to occur by an immune mediated process. The demyelinating lesions of MS can occur anywhere in the CNS including the brain stem and spinal cord. The presenting symptoms of MS
vary, but common symptoms are visual complaints, weakness, and sensory deficits. Although migraine can be associated with neurologic symptoms, one would expect more stereotypic events and a history of previous headaches.
Fibromyalgia is associated with numerous somatic complaints, but is not typically associated with sensory deficits or visual problems.
3. Which of the tests would be helpful in further diagnosing Multiple sclerosis?
Answer: Following tests would be helpful:
- Brain MRI : is 85–97% sensitive in detecting MS plaques. Multiple areas of increased signal in the periventricular area are suggestive of, but not specific for, MS. Gadoliniumenhancing
- Lumbar puncture : can also be useful. Cerebrospinal fluid (CSF) abnormalities suggestive of MS include oligoclonal bands and increased synthesis of IgG. A spinal fluid examination may be considered if the clinical diagnosis of MS is suspected but is not definite.
- Visual evoked potentials may also be helpful. Evoked potential may be used to aid in the diagnosis of MS by indicating prior demyelination of the optic tract (optic neuritis) if the clinical history is vague (e.g., eye pain without vision loss or no recollection of symptoms).
Answer: Immune-modulating therapy reduces the number of exacerbations and active lesions
on MRI. These include interferon-beta-1a (Avonex and Rebif) and interferon-beta-1b (Betaseron),
as well as glatiramer acetate (Copaxone). These medications are more efficacious if started early in the course of the disease. Common adverse effects of interferon include fatigue, depression, and myalgias.
Amantadine is given commonly as monotherapy and in combination with immunomodulatory therapy to treat fatigue associated with MS.
Corticosteroids have a role in treating severe acute exacerbations (e.g., optic neuritis, severe neurological impairments limiting activities of daily living) in the form of a short burst and taper (typically methylprednisolone, 1 g/day often followed by an oral prednisone taper). Oral steroid
use does not appear to offer long-term functional benefit, excluding the possible exception of IV pulsed steroid dosing.
Currently, oral immunosuppressive therapies (mycophenolate mofetil, azathioprine, and cyclosporin) are being considered in treating refractory MS, but their long-term efficacy and safety are not known.
Similarly, the value of IVIG and plasma exchange has not been conclusively demonstrated and use of these treatment modalities is reserved for refractory patients.
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