A 22-year-old woman comes to the physician with her husband for intermittent dizziness, weakness, and unsteady gait for the last several weeks. She has also had visual loss and pain in the right eye that worsens with eye movement for the past 2 days. A year ago, the patient had tingling and numbness of her right hand accompanied by unsteadiness, which improved spontaneously after 3-4 days. She has no other medical problems and does not take any medications. The patient has no significant social or family history. Her temperature is 37.2 C (99 F), blood pressure is 122/80 mm Hg, pulse is 82/min, and respirations are 16/min. On neurologic examination, her right eye has diminished visual acuity and an afferent pupillary defect. She also has a right arm intention tremor. Both lower extremities have spastic paresis, hyperreflexia, and positive Babinski sign. Appropriate investigation has confirmed the most likely diagnosis. Which of the following is the most appropriate next step in management of this patient?

Question

A 22-year-old woman comes to the physician with her husband for intermittent dizziness, weakness, and unsteady gait for the last several weeks.  She has also had visual loss and pain in the right eye that worsens with eye movement for the past 2 days.  A year ago, the patient had tingling and numbness of her right hand accompanied by unsteadiness, which improved spontaneously after 3-4 days.  She has no other medical problems and does not take any medications.  The patient has no significant social or family history.  Her temperature is 37.2 C (99 F), blood pressure is 122/80 mm Hg, pulse is 82/min, and respirations are 16/min.  On neurologic examination, her right eye has diminished visual acuity and an afferent pupillary defect.  She also has a right arm intention tremor.  Both lower extremities have spastic paresis, hyperreflexia, and positive Babinski sign. Appropriate investigation has confirmed the most likely diagnosis.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Treatment of acute multiple sclerosis (MS) exacerbation is indicated when disabling symptoms are present. Oral and intravenous (IV) corticosteroids are considered equally efficacious in hastening recovery. However, this patient has optic neuritis and should initially receive IV corticosteroids as oral corticosteroids are associated with an increased risk of recurrent optic neuritis (Choice D). An oral corticosteroid taper can be considered after IV therapy. Plasmapheresis should be considered in glucocorticoid-refractory patients (Choice A). (Choices B and E) There is not enough compelling evidence to recommend the use of IV immunoglobulins or pulse-dose cyclophosphamide for MS exacerbation. Educational objective: Acute multiple sclerosis exacerbation is treated with corticosteroids. Patients with optic neuritis should receive intravenous corticosteroids as oral agents may be associated with an increased risk of recurrence. Plasmapheresis can be used in refractory cases. References: A randomized, controlled trial of corticosteroids in the treatment of acute optic neuritis. The Optic Neuritis Study Group. (http://www.ncbi.nlm.nih.gov/pubmed/1734247) Oral versus intravenous steroids for treatment of relapses in multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/19588409)

A 22-Year-Old Woman Comes to the Physician with Her Husband