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. The patient returns to the physician due to painful muscle spasms. She has frequent episodes of pain and stiffness in both legs, especially when rising from her bed. She has tried home stretching exercise without significant relief. The patient is afebrile and has no new neurological deficits. Increased muscle tone is noted in the lower extremities. Laboratory evaluation, including electrolytes, is normal. Which of the following is the most appropriate next step in managing this patient's current symptoms?

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. The patient returns to the physician due to painful muscle spasms.  She has frequent episodes of pain and stiffness in both legs, especially when rising from her bed.  She has tried home stretching exercise without significant relief.  The patient is afebrile and has no new neurological deficits.  Increased muscle tone is noted in the lower extremities.  Laboratory evaluation, including electrolytes, is normal.  Which of the following is the most appropriate next step in managing this patient's current symptoms?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bffe_580c_8f63_0f07431b80ad_MD0005_00 Muscle spasticity is one of the most common disabling symptoms associated with multiple sclerosis (MS). It frequently involves the lower extremities and may result in pain/stiffness of the legs, especially when rising out of bed or a chair. First-line treatment for severe spasticity includes oral muscle relaxants such as baclofen or tizanidine, as these have similar efficacy and tolerability. Nonpharmacologic measures such as physical therapy and stretching exercises may also be helpful. (Choice A) Although amantadine may be considered in the treatment of MS-related fatigue, this patient's muscle stiffness and spasms are consistent with spasticity as opposed to fatigue. (Choice C) Benztropine is an anticholinergic medication that can treat drug-induced dystonia. Acute dystonic reactions may occur in patients receiving dopamine antagonist therapy (eg, antipsychotics, metoclopramide) and are characterized by sustained muscle contractions resulting in twisting or abnormal postures (eg, torticollis). Although this patient has increased lower-extremity muscle tone, her history of MS, lack of treatment with dopamine antagonists, and provocation of symptoms when getting out of bed make spasticity more likely. (Choice D) High-dose prednisone should be considered in the treatment of MS flare. The absence of new neurologic deficits in this patient makes the diagnosis less likely. (Choice E) Pyridostigmine is a cholinesterase inhibitor that can treat symptoms of myasthenia gravis. Although myasthenia gravis may be associated with proximal muscle weakness, it usually presents with ocular (eg, ptosis, diplopia) or bulbar (eg, dysarthria, dysphagia) weakness. Increased muscle tone and spasticity are not characteristic. Educational objective: Muscle spasticity is a common disabling symptom in patients with multiple sclerosis and frequently involves the lower extremities. First-line treatment for severe spasticity includes oral baclofen or tizanidine. Physical therapy and stretching exercises may also be helpful. References: Spasticity: pathophysiology, evaluation and management. (http://www.ncbi.nlm.nih.gov/pubmed/22976059)

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