Practical Management of MS in the Primary Care Office Setting Case Study 1

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 Case 1: Clinically Isolated Syndrome Presentation

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 Case 1 History

Case 1 Examination General: normal Neurologic –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

Case 1 Brain MRI, Axial FLAIR

Case 1 Brain MRI, T1 Hypointense Regions

Case 1 Brain MRI, T1 Postcontrast

Case 1 Cervical Spine MRI

Case 1 Differential Diagnosis Partial transverse myelitis Lupus Sarcoid Multiple sclerosis Other?

Case 1 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 1.Does this patient meet diagnostic criteria for MS? –If not, what else is needed? 2.Should this patient be offered disease-modifying MS therapy?