A 38-year-old woman comes to the emergency department due to a 3-day history of left arm and leg numbness. She also reports urinary urgency and incontinence but has no fever or dysuria. The patient was diagnosed with multiple sclerosis 10 years ago after an episode of right eye vision loss. She was taking disease-modifying therapy but stopped after being symptom-free for several years. Temperature is 37 C (98.6 F), blood pressure is 130/80 mm Hg, and pulse is 88/min. Sensation to light touch and pin prick is diminished on the left side. Neuroimaging reveals new areas of demyelination compared to previous MRIs. Which of the following is the most appropriate next step in management of this patient?

Question

A 38-year-old woman comes to the emergency department due to a 3-day history of left arm and leg numbness.  She also reports urinary urgency and incontinence but has no fever or dysuria.  The patient was diagnosed with multiple sclerosis 10 years ago after an episode of right eye vision loss.  She was taking disease-modifying therapy but stopped after being symptom-free for several years.  Temperature is 37 C (98.6 F), blood pressure is 130/80 mm Hg, and pulse is 88/min.  Sensation to light touch and pin prick is diminished on the left side.  Neuroimaging reveals new areas of demyelination compared to previous MRIs.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient with multiple sclerosis (MS), who now has new neurologic deficits (eg, left hemisensory loss, urinary incontinence) and areas of demyelination in the setting of medication discontinuation, is likely experiencing an acute MS exacerbation. Patients with MS exacerbation and disabling symptoms are typically treated with glucocorticoids (eg, intravenous methylprednisolone) as this hastens neurologic recovery. Mild sensory symptoms generally do not require corticosteroids. Plasmapheresis should be considered in patients with MS flare who are refractory to corticosteroid therapy (Choice G). (Choice A) Baclofen is a muscle relaxant that can be used to treat symptoms of muscle spasticity in MS; however, it does not hasten neurologic recovery from an acute MS flare. (Choices B and F) There is not enough compelling evidence to recommend the use of cyclophosphamide or intravenous immunoglobulins for MS exacerbation. (Choice C) Gabapentin may improve symptoms of neuropathic pain in patients with MS; however, it would not hasten neurologic recovery from an acute MS flare. (Choice E) Interferon beta and glatiramer acetate are disease-modifying agents used for chronic maintenance therapy as they decrease the frequency of exacerbations in patients with relapsing-remitting or secondary, progressive forms of MS. These agents have no proven role in the treatment of acute exacerbations. Educational objective: Acute exacerbations of multiple sclerosis with disabling neurologic symptoms are typically treated with glucocorticoids (eg, intravenous methylprednisolone). Plasmapheresis should be considered in patients who are refractory to corticosteroids. Interferon beta or glatiramer acetate can be used as chronic maintenance therapy in patients with relapsing-remitting or secondary, progressive forms of multiple sclerosis. References: Current and emerging therapies in multiple sclerosis: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/22783370) Management of acute exacerbations in multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/20182574)

A 38-Year-Old Woman Comes to the Emergency Department Due to a 3-Day