A 23-year-old woman complains that her right leg has become progressively stiff and clumsy over the last couple of weeks. She is worried as she has not been able to go to work for the last 4 days. On examination, tone is increased and there is a catch at the knee. She has six beats of clonus and an upgoing plantar. Power is reduced to 3-4/5 in the right leg flexors. There is no sensory involvement and the rest of the neurological exam is normal other than a pale disc on opthalmoscopy. On further questioning, she admits that she has had two episodes of blurred vision in her right eye in the last two years. Each lasted a couple of weeks from which she fully recovered. What is the most appropriate initial treatment?
A. A non-steroidal anti-inflammatory drug (NSAID)
C. Bed rest
E. A course of oral steroids
Ans: Multiple sclerosis treatment
(E) The subacute onset of upper motor neurone signs on a background of episodes of optic neuritis in a young woman makes relapsing–remitting MS the likely diagnosis. The diagnosis of MS hinges on the presence of multiple central nervous system (CNS) lesions separated by time and space. These manifest in either signs/symptoms or as enhancing white matter lesions on gadolinium-enhanced MRI. There is no specific role for NSAIDs in MS (A). Even if the patient complained of pain, it would be important to ensure its origin. NSAIDs would not be appropriate for neuropathic pain. This patient may be eligible for a disease-modifying drug such as interferon beta (B) or glatiramer acetate, as she has a relapsing–remitting course and recent symptoms, but this would not be the most immediate treatment. These drugs reduce the number of relapses experienced by one- third over two years and are expensive. Long-term effects on morbidity are currently unclear. Bed rest alone (C) is inappropriate as this patient would benefit from a course of steroids as she has disabling symptoms. Oral steroids (E) have been shown to be as effective as intravenous steroids, although patients tend to be admitted for IV treatment. They reduce the length of the relapse so the patient would recover quicker, but have no effect on number of relapses or accumulation of disability. There is no evidence for methotrexate (D) in relapsing–remitting MS.