Transcript Practical Management of MS in the Primary Care Office Setting

Practical Management of MS in the
Primary Care Office Setting
Case Study 1
Case 1: Clinically Isolated Syndrome
Presentation
• Mr. P, a 33-year-old right-handed white man, developed
numbness and tingling in his feet up to his mid-shins 4
days prior to presentation
• 3 days ago, he noted sacral and anal numbness
• 1-2 days ago, the numbness and tingling ascended to
involve the left side of his abdomen and upper back
• He denies weakness, difficulty with walking, visual
changes, vertigo, incoordination, bowel or bladder
dysfunction
• He has paresthesias with neck flexion
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History
• Personal history
– Currently limited to 5 beers/week
– Occasional marijuana use, no heroin or
cocaine
– Current medications: none
• Family history: No known history of
neurologic illnesses
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Examination
• General: normal
• Neurologic
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Mental status: normal
Cranial nerves: normal
Motor: normal
Sensory:
• Decreased light touch and pinprick to T7 on the left and T12 on
the right
• Lhermitte’s: positive
– Coordination: normal
– Reflexes:
• 3+ left triceps and biceps
• Otherwise 2+ throughout with downgoing toes
– Gait: normal
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Brain MRI, Axial FLAIR
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Brain MRI, T1 Hypointense Regions
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Brain MRI, T1 Postcontrast
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Cervical Spine MRI
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Differential Diagnosis
Partial transverse myelitis
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Lupus
Sarcoid
Multiple sclerosis
Other?
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Hospital Course
• Patient admitted for further evaluation
• Lyme, ANA, ENA, RPR, B12, HIV, ESR, and
CRP were unremarkable
• CSF
– Protein, glucose, cell count and opening pressure
were WNL
– 9 oligoclonal bands in CSF that are not present in
serum
Questions for Discussion
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Does this patient meet diagnostic criteria for MS?
– If not, what else is needed?
Should this patient be offered disease-modifying
MS therapy?