A 24-year-old woman comes to the emergency department due to sudden-onset blurry vision. She also describes intermittent numbness and tingling in the legs for the past several weeks. The patient has been under stress at school and is struggling to complete assignments on time. She is worried about her mother, who was recently diagnosed with breast cancer, and feels too distracted to concentrate. The patient's medical history is significant for 2 episodes of urinary incontinence that occurred 8 months apart and 1 episode of unilateral blindness that occurred after breaking up with her boyfriend last year. In each instance, her symptoms resolved spontaneously over several weeks without treatment. The patient has no other medical or psychiatric history. Brain MRI shows multifocal, white matter, hyperintense T2 lesions in the corpus callosum and periventricular area. This patient is most likely to develop which of the following conditions?

Question

A 24-year-old woman comes to the emergency department due to sudden-onset blurry vision.  She also describes intermittent numbness and tingling in the legs for the past several weeks.  The patient has been under stress at school and is struggling to complete assignments on time.  She is worried about her mother, who was recently diagnosed with breast cancer, and feels too distracted to concentrate.  The patient's medical history is significant for 2 episodes of urinary incontinence that occurred 8 months apart and 1 episode of unilateral blindness that occurred after breaking up with her boyfriend last year.  In each instance, her symptoms resolved spontaneously over several weeks without treatment.  The patient has no other medical or psychiatric history.  Brain MRI shows multifocal, white matter, hyperintense T2 lesions in the corpus callosum and periventricular area.  This patient is most likely to develop which of the following conditions?

Quizplus · Accepted Answer

This patient's history of >2 clinically distinct episodes of CNS dysfunction with resolution and hyperintense lesions on MRI is consistent with multiple sclerosis (MS). MS typically occurs in women age 15-50, is the most common autoimmune inflammatory demyelinating disease, and is characterized by a relapsing-remitting course of CNS dysfunction (eg, monocular blindness due to optic neuritis, motor and sensory loss/paresthesia below the level of the lesion, incontinence). Relapses of MS may be more common after stressful life events. (MS) Depression has been found in up to two-thirds of patients with MS and is the most common psychiatric complication. Depression can occur at any time and is likely caused by a combination of factors, including inflammatory changes in the brain, immune system changes, and psychological reactions to neurological deficits and the challenges of living with MS. Depression in MS is commonly underdiagnosed and undertreated. Appropriate treatment, including psychotherapy and antidepressants, can alleviate suffering and improve quality of life. (Choices A and G) Conversion disorder, or functional neurological symptom disorder, is characterized by neurological symptoms (eg, weakness, abnormal movements, nonepileptic seizures) that are inconsistent with a neurological disease. Somatic symptom disorder is characterized by excessive preoccupation with one or more unexplained somatic symptoms. This patient's symptoms are due to a known neurological disease. Patients with MS are not at increased risk of developing these disorders. (Choice B) Although cognitive impairment (eg, impaired attention, short-term memory, speed of information processing, executive function) is common in MS, frank dementia is not. Cognitive impairment in MS is exacerbated by untreated depression. (Choices D and E) Although patients with MS commonly experience anxiety related to their illness, they are not at increased risk of developing generalized anxiety or panic attacks. (Choice F) Psychosis may be a complication of high-dose glucocorticoids used to treat MS but is not a common complication of the disease itself. Educational objective: Multiple sclerosis is frequently associated with depression. Treatment, which includes psychotherapy and antidepressants, can alleviate suffering and improve quality of life. References: The link between multiple sclerosis and depression. (http://www.ncbi.nlm.nih.gov/pubmed/25112509) Recommendations on diagnosis and treatment of depression in patients with multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/24501169)

A 24-Year-Old Woman Comes to the Emergency Department Due to Sudden-Onset