Multiple sclerosis case studies Mohammad Wasay MD, FRCP, FAAN Aga - PowerPoint PPT Presentation

Multiple sclerosis case studies Mohammad Wasay MD, FRCP, FAAN Aga Khan University Karachi, Pakistan

Case one • A 29 year old nurse (married with two children) developed left side numbness and weakness over 3-4 days. Examination showed normal vision, left hemiparesis (3-4/5), left sided dysesthesia and left up going planters. Brain MRI showed bilateral periventricular lesions with contrast enhancement more prominent in right hemisphere consistent with MS.

• She was treated with steroids IV for three days and then PO for one month. Symptoms improved and she was able to start work after one month. After one month while she was on steroids taper she developed paraparesis with sensory level at T 7-8, bladder symptoms. MRI cervical spine normal. MRI thoracic spine showed demyelination and enhancement of spinal cord T6-8 level. She was again admitted and treated with steroids IV.

• Autoimmune workup including aquaporin antibodies was negative. After three weeks of steroids she partially improved but was unable to walk. Repeat Brain MRI showed new lesions. • Within six weeks she was admitted again with progressive weakness, shortness of breath, cough. Examination showed new left sided weakness. Brain MRI showed increased lesions with enhancement. Chest X ray showed pulmonary Tuberculosis.

• LP showed 105 cells predominantly lymphocytes, low glucose and elevated protein, PCR and Gene expert for TB negative, HSV negative, Multi PCR(BFA) negative. No OCB. She was started on ATT and steroids. Diagnosis of pulmonary TB and probable TB meningitis was made. She was discharged after one week

• At follow up after one month she is stabilized. Chest symptoms improved. Neurologically improved but still on wheel chair. • In 5 months she had three relapses. She received three courses of steroids. Every relapse was on tapering doses of steroids. • Now she also has pulmonary TB and probable TBM • No DMTs for MS

Case one • What would we have done differently? • What we should do now in terms of DMT? • She is EDSS 5 in 5 months. Why so aggressive MS? TB • R we dealing with MS or something else?