Multiple Sclerosis (Free Trial)

Cheuk Li
May 22
5 min read

Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓

Doctor Instruction:

You are a doctor working in family medicine. You have a 34-year-old woman, Sakura Haruno, presenting with numbness + tingling sensation affecting both hands and feet. Please take a history and perform an appropriate examination.

Patient History:

Sakura Haruno - a 34-year-old female - product manager in a health tech company.

You noticed tingling + numbness affecting both your hands and feet 2 weeks ago. You still have these symptoms– however, you think the symptoms are improving slightly recently. You have also noticed weakness affecting both your hands and feet. You recently had a COVID vaccination one week before developing these symptoms - you are not sure if this is related as you heard many stories about the side effects of the vaccination. You also felt sick after having the vaccination with flu-like symptoms for a few days.

Nowadays you also feel really tired – wanting to sleep more than usual. You don't feel like your usual self – always forgetting things. You have found yourself quite unsteady sometimes. Because of this, you had a few falls at home. Luckily you didn't hit your head. You just want to get better.

No incontinence/pain/Lhermitte’s sign/balance issues/weight loss/fever/problems with waterwork or bowel movement.

Mention only if asked: You remember having a problem with your right eye 5 months ago, and you remember having pain moving your eyes, a problem with vision and a bit of double vision. You can't remember much about this.

Ideas, Concerns, Expectations:

You think it is related to your COVID vaccination, and you are worried that you might also get blood clots from the vaccination, which can cause a stroke! Ask if this is true. You want to find out what is going on and see if you can have any blood thinners.

Past Medical History:

Obesity
Coeliac Disease
Hypertension

Drug History:

Atorvastatin
Rampiril
NKDA

Family History:

Mum has SLE.
Dad developed a stroke at the age of 50.

Social History:

You are a smoker who smokes 10 cigarettes/day for 3 years
Drink 2 cans of lager every night
Occupation: Product Manager in Healthtech
Managing well at home, living with a partner.

Examination Findings:

Weakness affecting both feet and hands
Spasticity/Increased muscle tone in the legs
Broad-based gait
Sensory ataxia – Romberg’s test positive

Differentials:

Multiple Sclerosis (symptoms/signs + history of optic neuritis)
Vitamin B12 Deficiency - Tiredness + coeliac disease + neurological signs
Guillain Barre Syndrome - Possible flu before symptoms, vaccination association, but would be primarily motor neuron dysfunction

Investigations:

Bedside:

Basic Observations
Capillary Glucose - assess for Hypoglycaemia as a cause of neurological symptoms

Bloods:

Baseline bloods – FBC/U&E/ LFTs/ CRP
FBC – may show macrocytic anaemia in B12 deficiency
LFTs – elevated AST + ALP in GBS
FBC – may show macrocytic anaemia in B12 deficiency
Vitamin B12 - low in B12 deficiency
Anti-ganglioside antibodies – may be positive in GBS

Imaging:

Fluid Attenuated Inversion Recovery (FLAIR) MRI of the brain and spinal cord to look for demyelinating lesions.

Special Tests:

Lumbar Puncture
- oligoclonal bands & raised IgG in CSF in MS
- elevated CSF protein in Guillain-Barre syndrome
Nerve conduction studies – slow nerve conduction velocity in GBS
Spirometry – reduced vital capacity in GBS

Data Interpretation:

Result Interpretation

Management (Multiple Sclerosis):

Conservative:

Patient & family/carer education
Provide prognostic information
Advise on MS support groups & charities available
Discuss care needs & refer to social services if any help is needed
Physiotherapy to improve mobility, strength & energy
Lifestyle modification e.g. regular exercise to maintain strength & reduce fatigue, smoking cessation
Shielding from infections e.g. SARS-CoV 19 or the flu where possible as infections are a common trigger of a relapse
Appropriate driving license authority - must be informed
Refer to neurology
Regular review for symptoms and care needs

Medical:

Acute Relapse of MS:
- Non-severe & social needs can be met at home: PO 500mg methylprednisolone
- Severe & social needs cannot be met at home: IV 1g methylprednisolone
- Consider plasmapheresis if severe & not responsive to steroids
Immunomodulator e.g. interferon beta to treat ongoing relapsing-remitting MS
Anti-CD20 monoclonal antibody e.g. ocrelizumab to treat primary progressive MS
Siponimod for secondary progressive MS