A 32-year-old woman comes to the office with several days of tingling and numbness in her right hand. She moved from Oregon to Arizona earlier this summer to care for her ailing mother who died 2 weeks ago of Alzheimer dementia. Since moving, the patient has had occasional headaches, dizziness, fatigue, poor sleep, and double vision. She has had no fevers, weight loss, or anorexia. Medical history is unremarkable. The patient drinks 1 or 2 glasses of wine daily but does not use tobacco or recreational drugs. Blood pressure is 132/70 mm Hg and pulse is 78/min. Sensation to light touch and pain is decreased distally in the right upper extremity. Muscle strength is 5/5 in the upper and lower extremities and deep tendon reflexes are normal. Gait is normal. There is ophthalmoplegia of the right eye on rightward gaze. Which of the following is the next step in diagnosis?
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This patient has 2 separate neurologic deficits that cannot be explained by a single lesion (right hand sensation deficits, lateral rectus palsy), associated with constitutional symptoms (eg, fatigue, poor sleep) possibly worsened by heat exposure (moved to a hotter location during the summer). In a young woman, this is suspicious for the first presentation of multiple sclerosis (MS). A confirmed diagnosis of MS requires deficits disseminated in both:
This patient has neurologic deficits disseminated in space, but it is unclear if they are disseminated in time. Therefore, a careful review of her history for any suspicious neurologic symptoms that may represent a previous attack is warranted. In addition, MRI of the brain and spinal cord should be obtained because the presence of old lesions can prove dissemination in time. Oligoclonal bands can be used as evidence of ongoing inflammation. If none of these confirm dissemination in time, close follow-up may reveal new attacks or new lesions on MRI.
(Choice A) CT scan of the cervical spine may be considered when there is concern for cervical spine disease (eg, spinal or neuroforaminal stenosis). Patients generally present with neck pain and can have hand/arm numbness and weakness; however, this would not cause lateral rectus palsy or constitutional symptoms.
(Choice C) Nerve conduction studies help diagnose peripheral nervous system disorders (eg, entrapment neuropathies, polyneuropathies); however, lateral rectus palsy would not be explained by a peripheral neuropathy.
(Choice D) Wilson disease (due to copper accumulation) can present with diverse constitutional and neurologic findings. However, the most common are dysarthria, gait abnormalities, and dystonia, not present in this patient. In addition, heat sensitivity and localizing neurologic findings (hand, eye) are more consistent with MS.
(Choice E) Wernicke encephalopathy (from thiamine deficiency) can present with ophthalmoplegia. However, ophthalmoplegia is classically accompanied by ataxia and encephalopathy (not present in this patient) and occurs in the setting of an obvious risk factor for thiamine deficiency (eg, chronic alcohol overuse, malnutrition, hyperemesis gravidarum).
Educational objective:
Multiple sclerosis presents with neurologic deficits disseminated in both space and time. Initial presentations may not be disseminated in time, but further work-up and/or follow-up can lead to a confirmed diagnosis.