Snapshot A 20-year-old woman is brought to the ER 30 minutes after acute onset of double vision in the left eye. Two months ago, she had an acute episode of pain with movement of the left eye along with loss of both central vision and pupillary light reflex. These symptoms subsided spontaneously. Examination shows a delay in the adduction of the left eye with nystagmus of the right eye on lateral gaze Introduction Acquired demyelinating disease of the CNS May have a T-cell mediated autoimmune pathogenesis Twice as common in woman and has a peak incidence at 20-40 years Associated with temperate climates (northern latitudes) Defined by two distinct episodes of focal neurologic deficits Presentation Symptoms limb weakness optic neuritis paresthesia diplopia urinary retention vertigo symptoms may wax and wane or be progressive Physical exam Positive Babinski MLF syndrome (Internuclear Ophthalmoplegia) Evaluation CSF analysis mononucleur pleocytosis (25%) elevated CSF IgG (80%) oligoclonal bands on electrophoresis lumbar puncture is indicated if MRI is non-diagnostic MRI considered best diagnostic modality multiple focal demyelination scattered in brain and spinal cord asymmetric periventricular plaques Differential CNS mass lesion, vitamin B12 deficiency, sarcoidosis, CNS infections Treatment Steroids during acute exacerbations Prophylactic immunosuppresants or beta interferon may decrease the number and severity of relapses interferon beta or glatiramer acetate have been shown to decrease the progression of relapsing remitting multiple sclerosis interferon beta or glatiramer acetate are teratogenic women of childbearing age should be on contraception when using these medications Prognosis, Prevention, and Comlications Variable types of disease progression from rapid death to prolonged remission Initial presentation with sensory symptoms associated with more benign disease course High Yield A young woman presents with relapsing and remitting neurological symptoms including fatigue, optic neuritis, urinary incontinence, hyperreflexia and depression. She also has many other non-specific motor and sensory symptoms. best initial test: MRI most accurate test: MRI confirmatory test: lumbar tap looking for oligoclonal bands in the CSF (only when MRI is not diagnostic) best initial treatment: steroids - for acute exacerbations long term treatment (disease-modifying): beta-interferon, glatiramer, natalizumab, mitoxantrone