I follow a young female, 11 years old, whose symptom onset was diplopia lasting 1 week, responsive to IV corticosteroids. The first MRI, performed 2 weeks after the onset, showed a single subcortical white matter left frontal lesion, of about 3 cm in diameter, without contrast enhancement. Tests for sarcoidosis were negative, while CSF showed 3 oligoclonal bands. MRI after a couple of months revealed 2 new very small lesions in the temporo-occipital peritrigonal subcortical white matter without contrast enhancement, with the old lesion unmodified. After 1 year, the same symptomatology recurred with transient diplopia of few days, responsive to corticosteroids. At this point diagnosis of relapsing-remitting MS (RRMS) was established with no new lesions on a third MRI. To date, after 3 years, this young female did not show new symptoms without adding further treatment. She has completed her growth normally. What's your prognosis?
Ennio Montinaro, MD
from Rohit Bakshi, MD, 09/25/01
Your patient seems to have several features that are consistent with a favorable prognosis of RRMS. A number of prognostic factors have been suggested as summarized below, but most of these are considered of limited value.
Prognostic Factors in Multiple
|Onset: Relapsing-remitting||Onset: Progressive disability|
|Onset: Optic neuritis||Onset: Pyramidal involvement|
|Onset: Sensory involvement||Onset: Cerebellar involvement|
|Onset: Age < 30||Onset: Age > 40|
|Onset: Low MRI T2 lesion burden||Onset: High MRI T2 lesion burden|
|Infrequent attacks||Frequent attacks|
Adapted from Ebers and Paty
However, the prognosis in a given patient with MS usually cannot be determined with a high level of certainty. The clinical course is heterogenous and variable within and across subjects. It was previously thought that a subset of MS patients, perhaps 10% to 25%, had a benign course. Recent data have called into question the existence of a truly "benign" subtype. When "benign" subjects are followed over decades, sustained disability often develops.
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