Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.
A 35-year-old African American female (AAF) with a past medical history (PMH) of mutliple sclerosis (MS) is admitted with a chief complaint of generalized weakness and inability to walk. At baseline, she is able to transfer independently from a bed to a chair and to walk with assistance. Her PMH is positive for urinary incontinence and frequent urinary tract infections (UTIs) that lead to MS flares. The current complaints are typical of her MS flares.
She also complains of (c/o) nausea and has vomited in the emergency room (ER). She reports no abdominal pain or dysuria.
Past medical history (PMH)
Multiple Sclerosis (MS), treated with methylprednisolone IV (IVMP) every 2 months, each course consists of Solu-Medrol 1 gm over 30 min for 3 days. UTIs, urinary incontinence, presenile dementia, hypercholesterolemia.
Detrol (tolterodine), multivatimin (MVT).
VS 38.2-95-128/80-18 SpO2 98% on RA.
HEENT: dry MM, no nuchal rigidity.
Chest: CTA (B).
CVS: Clear S1S2.
Abdomen: Soft, NT, ND, +BS, wears a diaper.
Ext: no c/c/e.
Neuro: AAO x 3.
Strength 5/5 (B) UE, 0/5 RLE, 1/5 LLE, her baseline strength is 2/5 RLE, 4/5 LLE.
Sensation is intact, DTR are increased, and there is spasticity.
What is the most likely diagnosis?
Multiple Sclerosis (MS) Exacerbation.
What is the reason for the MS flare in this patient?
It could be any infection, e.g. UTI or URTI. If it is summer, and there is no air conditioning in the patient's room, hot weather may be the reason for the MS flare.
What laboratory tests would you recommend?
Blood cultures (BC) x 2
Chest X-ray (CXR)
The urinalysis (UA) showed evidence of UTI.
The white blood cell count (WBC) was elevated to 18.2 with 75% PMN.
The basic metabolic panel (BMP) was within normal limits (WNL).
Ciprofloxacin 500 mg IV q 12 hr was started, along with NS at 150/hr for 2 L.
A neurology consult was called, and she recommended treating the UTI first, then reevaluating the patient to see if she needs IVMP.
The MRI showed chronic lesions of MS.
What happened next?
Solu-Medrol was started at 1000 mg IV q 24 hr x 3. The patient's condition improved significantly on the second day of IVMP treatment, with the recovery of her motor function to baseline, 4/5 LLE. She was discharged home with a prednisone taper, 40 mg PO qd x 5 d, 30 mg PO qd x 5 d, 20 mg PO qd x 5 d, then stop.
Multiple Sclerosis (MS) exacerbation due to UTI.
What did we learn from this case?
Infections are a common reason for MS exacerbations. It is generally advisable to consult a neurologist early. Typically, MS patients are followed closely by their neurologist, and it is important to compare the current neurological complaints to their baseline status. Always ask if this attack is typical of their MS flares.
Consider interferon treatment, if recommended by the neurology consult.
Multiple Sclerosis. Merck Manual.
Multiple Sclerosis. The Cleveland Clinic.
UTIs May Trigger Relapse in Multiple Sclerosis. Journal of Urology, 1999.
Role of bacterial infection in exacerbation of multiple sclerosis. Am J Phys Med Rehabil, 1995.
People with MS: Comedian Richard Pryor dies at 65. CNN, 12/05.
Anti-CD20 monoclonal antibody ocrelizumab helps patients with relapsing-remitting multiple sclerosis (MS) (Lancet, 2011).
Patient Voices: Multiple Sclerosis - Interactive Feature - NYTimes, 2011.
Multiple Sclerosis Overview - Mayo Clinic YouTube http://bit.ly/181FCi4