A 26-year-old, previously healthy woman presents in a neurologist’s office with a 1-week history of horizontal double vi
Posted: Mon May 23, 2022 1:46 pm
A 26-year-old, previously healthy woman presents in a
neurologist’s office with a 1-week history of horizontal double
vision, particularly when she looks to the right. She denies pain,
loss of visual acuity, and other neurologic symptoms. Examination
reveals an internuclear ophthalmoplegia, the most common syndrome
affecting eye movements in MS. The patient’s neurologic examination
is otherwise unremarkable. A spinal tap is significant for the
presence of oligoclonal bands and elevated immunoglobulin G (IgG)
index, with a value of 1.5 (normal isles than 0.7). Oligoclonal
bands and elevations in IgG index are nonspecific markers of
central nervous system (CNS) inflammation that are described in a
multitude of infectious, inflammatory, and neoplastic CNS diseases
in addition to MS.
1a. If you were the clinician, would you diagnose the
patient at this point with clinically definite multiple sclerosis
(CDMS)? Why or why not?
1b. What other tests or diagnostic tools would you use to
determine the existence of CDMS?
The clinician orders one of the diagnostic tools you’ve suggested,
above, and finds that the brain and cervical spinal cord are normal
with the exception of a lesion in the pontine tegmentum in the
region of the medial longitudinal fasciculus (Note: you can Google
that location if you want, but the key point here is that this
single diagnostic investigation has revealed a single
lesion).
2. Would you diagnose the patient with CDMS at this point?
Why or why not (Note: keep the McDonald Criteria in
mind).
3. Assuming that the patient was not significantly
debilitated by the vision impairment, would you treat the patient?
Why or why not?
Several months later, the patient schedules a follow-up visit due
to the emergence of new symptoms. There has been reemergence of her
vision disorder and she has experienced week-long numbness and
clumsiness in her right hand. A new diagnostic investigation
reveals multiple white matter lesions.
4. Would you diagnose the patient with CDMS at this point?
Why or why not (Note: keep the McDonald Criteria in
mind).
neurologist’s office with a 1-week history of horizontal double
vision, particularly when she looks to the right. She denies pain,
loss of visual acuity, and other neurologic symptoms. Examination
reveals an internuclear ophthalmoplegia, the most common syndrome
affecting eye movements in MS. The patient’s neurologic examination
is otherwise unremarkable. A spinal tap is significant for the
presence of oligoclonal bands and elevated immunoglobulin G (IgG)
index, with a value of 1.5 (normal isles than 0.7). Oligoclonal
bands and elevations in IgG index are nonspecific markers of
central nervous system (CNS) inflammation that are described in a
multitude of infectious, inflammatory, and neoplastic CNS diseases
in addition to MS.
1a. If you were the clinician, would you diagnose the
patient at this point with clinically definite multiple sclerosis
(CDMS)? Why or why not?
1b. What other tests or diagnostic tools would you use to
determine the existence of CDMS?
The clinician orders one of the diagnostic tools you’ve suggested,
above, and finds that the brain and cervical spinal cord are normal
with the exception of a lesion in the pontine tegmentum in the
region of the medial longitudinal fasciculus (Note: you can Google
that location if you want, but the key point here is that this
single diagnostic investigation has revealed a single
lesion).
2. Would you diagnose the patient with CDMS at this point?
Why or why not (Note: keep the McDonald Criteria in
mind).
3. Assuming that the patient was not significantly
debilitated by the vision impairment, would you treat the patient?
Why or why not?
Several months later, the patient schedules a follow-up visit due
to the emergence of new symptoms. There has been reemergence of her
vision disorder and she has experienced week-long numbness and
clumsiness in her right hand. A new diagnostic investigation
reveals multiple white matter lesions.
4. Would you diagnose the patient with CDMS at this point?
Why or why not (Note: keep the McDonald Criteria in
mind).