A 19-year-old woman with a history of migraine headaches initially presented with subacute onset of double vision and vertigo.

The following case study was provided by Daniel Ontaneda, MD, and Marisa McGinley, DO, both neurologists at the Cleveland Clinic in Ohio. In addition, Dr Ontaneda is a co-primary investigator of the international Determining the Effectiveness of Early Intensive Versus Escalation Approaches for the Treatment of Relapsing-Remitting Multiple Sclerosis (DELIVER-MS; NCT03535298) trial, which recently opened.

A 19-year-old woman with a history of migraine headaches initially presented with subacute onset of double vision and vertigo. This occurred shortly after an upper respiratory tract infection that had been presumed to be viral. In relation to double vision, she described objects as side by side and worsening of double vision when looking at objects at a distance. She was seen in the emergency department and found to be nonfebrile. She was informed of a diagnosis of possible labyrinthitis and was discharged home. She improved slowly over the course of 3 weeks, but had residual double vision.

Five months after initial presentation, the patient developed numbness and tingling in her right lower extremity, which spread to involve both legs, followed by weakness in her legs. Numbness and tingling then ascended up to the midabdominal region. This was followed by urinary frequency and urgency. She was admitted to the hospital.

On neurological exam, she had evidence of a left-sided internuclear ophthalmoplegia, bilateral lower extremity weakness with increased tone, up-going plantar response on the left, and sensory level to pinprick and soft touch at T6.

Magnetic resonance imaging of the brain showed the presence of scattered areas of T2 prolongation in the peri-ventricular, juxta-cortical, corpus callosum, and brainstem. Lesions were ovoid, and periventricular regions radiated perpendicular to the lateral ventricles. Two of the juxta-cortical lesions demonstrated enhancement in an open ring configuration. A total of 5 other lesions demonstrated nodular enhancement. Magnetic resonance imaging of the cervical and thoracic spine showed nonenhancing lesions at C2-C3 and C5-C6, and an enhancing lesion at T4.

A diagnosis of multiple sclerosis (MS) was confirmed. The patient was treated with 5 days of intravenous methyl prednisolone. She made a partial recovery with residual weakness, sensory disturbance, and mild urinary incontinence. In a follow-up visit with a MS specialist, a decision was made to start the patient on an early, highly effective therapy, and ocrelizumab was started as a disease-modifying agent.


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