Case: 21-year-old Woman with Blurry Vision

00:02 In this talk, we're going to review multiple sclerosis, which is our classic recurrent T cell-mediated CNS immune disorder.

00:11 So let's start with a case.

00:13 This is a 21 year old woman, who presents to your clinic today as a new patient visit for blurry vision.

00:19 This began two weeks ago when she first noted that her right eye was sore.

00:25 Several days later, she noted that her right eye began to become blurry, and within a week later, it had progressed to the point that she couldn't see nearly anything out of it.

00:34 At this point, she went to an optometrist who center for an MRI of the brain.

00:39 After her MRI, she was referred to you in Neurology based on those findings.

00:44 She reports that about three months ago, she had the onset of numbness and tingling in the left leg and arm, which slowly progressed over the course of a couple of weeks.

00:55 She states that initially started in her distal foot and slowly ascended to the level of her knee with numbness in her arm, to the level of her elbow.

01:04 Both regions seem to be continuing to progress at this point in time.

01:09 So there's a few interesting features and important features of this case that you want to hone in on.

01:15 The first is the timeline of onset.

01:18 The symptoms in her eye began over a course of two weeks.

01:21 That's a sub-acute onset condition and should raise possibility for an inflammatory condition.

01:28 The second is the evolution over time.

01:30 They progressed gradually and rapidly, as we would expect for an immune attack.

01:38 And then there's multiple localizations.

01:40 We have the new symptoms in the right eye that sound monocular, the sounds like a prechiasmatic lesion in the right eye.

01:47 And then the spinal cord related symptoms with asymmetric numbness and tingling in the leg and arm, sparing the face without brainstem or cranial nerve symptoms suggestive of a spinal cord lesion.

01:58 It's that separation in with multiple locations is concerning for an autoimmune condition like MS.

02:08 The patient underwent MRI of the brain.

02:10 And here we're looking at the coronal flare, and we can see a increased signal within the right optic nerve, which you can see with the arrow.

02:19 And you can compare that to the left optic nerve which is smaller and not as bright as on the normal side.

02:26 The patient had visual field testing, which were intact a confrontation.

02:30 Fundoscopic examination was without optic disc pallor or edema.

02:34 There's not something we can see within the optic nerve.

02:37 And her visual acuity was 20/20 in the left eye, and 20/70 in the right eye with red desaturation in the right eye.

02:44 So color desaturation.

02:47 So what's the most likely diagnosis in this patient? Is it MS? NMO or neuromyelitis optica? Clinically isolated syndrome? Or is this an ischemic optic neuropathy? Well, this doesn't sound like a clinically isolated syndrome.

03:02 The patients presenting with new vision complaints in the right eye and a prior episode of what sounds like a spinalcord syndrome.

03:09 And that multiple presentations makes us concern for recurrent syndrome, like MS, NMO, antiMOG disease, or some other similar condition.

03:20 This doesn't sound like NMO.

03:22 This patient has a presentation of the unilateral visual field defect and we often see bilateral optic neuritis, which would raise a stronger suspicion for NMO.

03:33 NMO would be a consideration in this patient, but it's not the most likely diagnosis based on the information that we have.

03:40 This doesn't sound like an ischemic optic neuropathy.

03:43 The time course and onset of this patient's presentation is more suggestive of an inflammatory condition as opposed to ischemic optic neuropathy.

03:51 And so multiple sclerosis is the right answer here.

03:54 That is the most likely diagnosis and requires additional workup but the clinical features are suggestive of a diagnosis of MS.