Review Question - QID 105699

This patient presents with signs and symptoms concerning for optic neuritis, which is most commonly due to multiple sclerosis (MS). Oligoclonal bands in the CSF are diagnostic of MS.

MS is an autoimmune disorder characterized by inflammation and demyelination of the central nervous system (Illustration A). It most often affects caucasian women in the third or fourth decade of life. It can present with a large constellation of neurologic symptoms including: optic neuritis, intranuclear ophthalmoplegia, hemiparesis, hemisensory symptoms, and bladder incontinence (Illustration B). Classically, patients present with neurologic symptoms that are disseminated in time (symptoms that resolve and are followed later by different symptoms) and space (symptoms affecting different body parts). MS often proceeds via a relapsing and remitting course (Illustration C). On MRI, the characteristic periventricular plaques ("Dawson's fingers") are observed which is characteristic of MS. On CSF analysis, oligoclonal bands are observed on electrophoresis (Illustration D) which are diagnostic for MS. Oligoclonal bands are composed of IgG and are observed in 75-85% of patients with MS.

Tafti et. al review the clinical manifestations, diagnosis and management of multiple sclerosis. Among others, they note optic neuritis as a common neurologic manifestation of MS. They discuss the diagnosis of MS and note the importance of oligoclonal bands on CSF analysis in conjunction with findings on MRI of the brain and spinal cord.

Illustration A demonstrates the pathophysiology of demyelination in MS. Illustration B demonstrates the symptoms seen in MS. Illustration C demonstrates the different patterns of MS including relapsing remitting and primary progressive. Illustration D demonstrates the oligoclonal bands observed in MS.

Incorrect Answers:
Answer 1: Albuminocytologic dissociation, which refers to elevated CSF with protein with normal cell count, is observed in Guillan-Barre syndrome but is not observed in MS

Answer 2: Elevated lymphocyte count and protein concentration on CSF analysis would point toward a number of different CSF infectious processes (most notably viral or TB meningitis), but would not be expected in MS.

Answer 3: Elevated opening pressure is seen in meningitis (especially cryptococcal meningitis) and normal pressure hydrocephalus, along with other causes of elevated intracranial pressure, but is not observed in MS.

Answer 4: Normal findings on CSF analysis would point to an etiology outside of the CNS to explain this patient's symptoms. However, this patient's age, sex, and constellation of neurologic symptoms disseminated in time and space are classic for MS.


Bullet summary:
Multiple sclerosis may present with a variety of neurologic symptoms, and oligoclonal bands in cerebrospinal fluid are diagnostic.