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Practice Buzz: How do you manage the initial clinical presentation of multiple sclerosis?

While recognizing each case is different, please choose the answer that best reflects your common practice and limit free text to strategies that are not included.

Estimated Time: 5 Minutes

CASE
A 36-year-old woman presents with a 3-day history of painful right eye vision loss. Fundoscopic examination is unremarkable. Corrected visual acuity is 20/70 OD and 20/20 OS. There is a right Relative Afferent Pupillary Defect (RAPD). The patient has mild adiadochokinesia in the left upper limb, of which she was not aware. The remainder of the neurologic examination is normal. Brain MRI shows gadolinium enhancement of the right posterior optic nerve, as well as several non-enhancing T2 periventricular hyperintensities and one 5mm T2 hyperintensity in the right cerebellar hemisphere.
1. Which of the following tests would you include as part of your initial workup for this patient? Check all that apply or select "None of the above." *This question is required.
2. MRI of the cervical spine shows a 4mm non-enhancing lateral cord hyperintense T2 lesion at C4. MRI of the thoracic spine is unremarkable. CSF shows 4 lymphocytes, 0 erythrocytes and protein 0.32. Oligoclonal bands and serology are pending. Given the patient’s 3-day history of painful right eye vision loss with a corrected visual acuity of 20/70, would you offer this patient a therapy for management of an episode of an autoimmune demyelinating condition? *This question is required.
What would you offer this patient for relapse management? *This question is required.
Would you offer this patient a therapy for relapse management if their symptoms were non-disabling? (e.g. mild sensory loss).
3. The results show 2 oligoclonal bands in the CSF that are not matched in serum. Anti-MOG IgG and anti-aquaporin 4 IgG are not detected in serum. Would you consider this patient to be at a high risk of developing severe course of multiple sclerosis?
4. What would you consider to be the most appropriate initial disease-modifying therapy in this patient (assuming no risk of pregnancy)? Select all that apply. *This question is required.
  • * This question is required.
6. How often would you recommend this patient be seen by a neurologist or MS specialist? *This question is required.
7. How often would you recommend imaging for this patient? *This question is required.
8. What type of imaging would you recommend for this patient? *This question is required.
9. Within 2 months, the patient's vision returns to normal. At 6 months she remains only mildly symptomatic with the subtle left-sided neocerebellar syndrome unchanged. One year later, the patient presents to her routine appointment with subjectively no change in neurologic symptoms, but her examination reveals bilateral subtle adiadochokinesia and her non-contrast brain MRI shows two new hyperintense T2 lesions – a 5mm lesion in the right cerebellar hemisphere and a periventricular lesion in the right parietal lobe. What strategy for further disease modifying therapy would you choose? *This question is required.