Multiple Sclerosis
Patient Presentation
A 25 y/o female, T.F., presents to the ED complaining of severe (8/10) pain
behind the eyes with weakness and pain in her left upper and lower
extremities that started 2 days before. She reports no visual changes. T.F.
has a past medical history of fibromyalgia, multiple sclerosis with episodes
of optic neuritis. Her most recent MS exacerbation was over a month ago, and
she received 5 days of inpatient IV Solu-Medrol®. T.F. was originally
scheduled to follow up with the neurologist the day after this presentation
to the ED, to discuss treatment options.
Differentials
Relapsing-Remitting Multiple Sclerosis: Considering the patient’s history of
MS, the recurrence of old symptoms (optic neuritis), and the new onset of
weakness, the medical team’s primary presumption was that T.F. was
experiencing an MS exacerbation.
Diagnosis
Neuro exam showed patient AAAOx3, follows commands, appropriate & clear
speech, PERLA with photophobia, extraocular muscles intact without
nystagmus, positive pain with eye movement. Face symmetrical, palate and
tongue midline, hearing intact. Coordination tests: no dysmetria;
finger-to-nose and heel-to-shin intact. Motor: Positive for drift in left
upper extremity. Strength 5/5 right upper and lower extremities, 4/5 in left
extremities; normal tone. Transfers from bed-to-chair with assistance.
Sensory: decreased sensation to touch and pinprick below ankle on LLE.
Positive paresthesias to touch on LUE and LLE.
Treatment
Under the care of the Neurology service, T.F. received IV steroid
Solu-Medrol® 1g daily for 5 days. For pain, she was given Dilaudid® 1mg IV
q6H PRN and continued her home medications of Klonopin®, Cymbalta®, Lyrica®,
Ultram®, and MiraLax®. During the hospitalization, T.F. experienced multiple
episodes of tremors at night in the BLE, which Ativan® relieved.
Outcome
By the 5th day, T.F.’s pain had decreased and her left-sided strength had
improved. The patient was discharged home and scheduled to be readmitted in
2 weeks for chemotherapy medication to treat the MS.