Jun 12, 2003
Multiple sclerosis/Neuroimmunology Ask The Expert
from Medscape Neurology & Neurosurgery
Would you recommend immunomodulatory therapy in a patient with a single lesion by magnetic resonance imaging (MRI)? The patient is a 40-year-old woman with onset of paresthesia and fatigue. Nerve conduction velocity and visual evoked potential are normal, but hyperreflexia is apparent on physical examination. MRI shows a single lesion at C4, and cerebrospinal fluid has oligoclonal bands. History reveals an episode at age 30 with similar symptoms resolving in 6 weeks (no MRI done). She is currently diagnosed with transverse myelitis.
from Omar Khan, MD, 06/12/2003
Treatment considerations ultimately will depend on the results of her MRI. If an additional MRI has not yet been performed, it should be. If the MRI is normal, I would not initiate therapy at this time. Instead, simply repeat the brain and cervical spine MRI in 6 months.
Her current diagnosis is transverse myelitis, in addition to a possible remote multiple sclerosis (MS) episode 10 years ago. Or, she may have recurring transverse myelitis. There does not appear to be evidence of MS disease dissemination by MRI. Given this information, it would be premature to assume that she has MS at this time and to prescribe disease-modifying therapy (DMT).
However, if the repeat brain MRI is abnormal and consistent with MS, then I would begin DMT at this time. Those results would provide evidence of dissemination by MRI criteria. In that case, it is virtually guaranteed that MS will eventually develop in this woman. Finally, one has to ensure that other diagnostic considerations -- lupus, sarcoidosis, CT disorders, Lyme disease, among others -- have been eliminated.
Bakshi R, Kinkel PR, Mechtler LL, et al. Magnetic resonance imaging findings in 22 cases of myelitis: comparison between patients with and without multiple sclerosis. Eur J Neurol. 1998; 5:35-48.
Goodin DS, Frohman EM, Garmany GP, et al. Disease modifying therapies in multiple sclerosis: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the MS Council for Clinical Practice Guidelines. Available at: http://www.aan.com/professionals/practice/pdfs/gl0091.pdf Accessed June 4, 2003.
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About the Panel Members
Omar Khan, MD, Associate Professor of Neurology and Medical Director, Multiple Sclerosis Clinic, Wayne State University, Detroit, Michigan
Medscape Neurology & Neurosurgery 5(1), 2003.
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