Case Report: Multiple sclerosis in a 28-year-young female

Dhanalakshmi Kaliyaperumal1, Z. Ahamed Rithabudin2

1Clinical Pharmacist, Kauvery Hospital, Vadapalani, Chennai

2Clinical Pharmacist, Kauvery Group of Hospitals, Chennai

Abstract

Multiple Sclerosis (MS) is a chronic, immune-mediated, inflammatory demyelinating disorder of the central nervous system (CNS). It presents with a wide array of neurological symptoms and is characterized by the presence of multifocal lesions in the CNS. This case report discusses a 28-year-old female presenting with acute neurological symptoms, including giddiness, unsteadiness of gait, right lower limb numbness, and chronic diplopia. Magnetic Resonance Imaging (MRI) revealed multifocal T2/FLAIR hyperintense lesions in the brainstem, cerebellar peduncles, and subcortical white matter, along with diffuse patchy lesions in the spinal cord. Cerebrospinal fluid (CSF) analysis showed mildly elevated glucose levels, normal protein levels, and negative NMO/MOG antibodies. The patient was diagnosed with probable MS and managed with high-dose intravenous corticosteroids followed by oral tapering. This case underscores the importance of early recognition, neuroimaging, and targeted therapy in suspected MS.

Keywords

Multiple Sclerosis, Demyelinating Disease, MRI, Cerebrospinal Fluid, Corticosteroids, Neurological Symptoms

Introduction

Multiple Sclerosis (MS) is the most common chronic inflammatory demyelinating disease of the CNS, primarily affecting young adults. The etiology remains incompletely understood but is believed to involve a combination of genetic susceptibility and environmental factors. Clinically, MS is characterized by episodes of neurological dysfunction separated in time and space, affecting different anatomical locations. Diagnosis is based on clinical presentation, MRI findings, and CSF analysis, with the McDonald criteria serving as the standard for diagnosis.

Case Presentation

Patient Information

Name: Mrs. D

Age/Sex: 28 years / Female

History of Present Illness

The patient presented with:

  • Giddiness and unsteadiness while walking for 2 days.
  • Numbness over the right thigh and right calf region for 2 days.
  • Double vision (diplopia) persisted for 5 months.
  • One episode of vomiting.

Past Medical History

  • History of lumbar disc bulge at L4-L5 since May 2024.

Family and Social History

  • No significant family history of neurological disorders.
  • Non-smoker; Non-Alcoholic

Investigations

Laboratory Investigations

TestResultInterpretation
Hemoglobin (Hb)11.6 g/dLMild anemia
CSF Glucose103 mg/dLMildly elevated; may indicate blood-brain barrier disruption
CSF Protein32.9 mg/dLNormal
CSF CytologyNo Atypical cells seen-
Serum NMO AntibodiesNegativeNo evidence of neuromyelitis Optica spectrum disorder
Serum MOG AntibodiesNegativeNo evidence of myelin oligodendrocyte glycoprotein antibody-associated disease

Imaging Studies

MRI Brain:

  • Multifocal small T2/FLAIR hyperintense lesions in:
    • Brainstem
    • Bilateral middle cerebellar peduncles
    • Bilateral frontal and temporal subcortical white matter

MRI Whole Spine:

  • Diffuse patchy T2 hyperintense lesions along the entire cord from cervical to conus level, more conspicuous in the cervical region causing cord expansion.

Diagnosis

Based on clinical presentation, MRI findings, and laboratory investigations, the patient was diagnosed with probable Multiple Sclerosis. The negative NMO/MOG antibody tests helped exclude neuromyelitis Optica spectrum disorders.

Treatment

Hospital Management

The patient was administered:

Drug NameGeneric name / StrengthFrequencyRoute of adminDays
Inj. Solumedrol (Methylprednisolone)1 g1-0-1IV3 days
Inj. Pan (Pantoprazole)40 mg1-0-0IV3 days
Tab. Myospas (Thiocolchicoside)1 tab1-0-1P/O3 days

Discharge Medications

DrugDoseFrequencyTimingDuration
Tab. Medrol8 mg1-0-1After food26/08/25 – 30/08/25
Tab. Medrol4 mg1-0-1After food31/08/25 – 04/09/25
Tab. Medrol4 mg1-0-0After food05/09/25 – 09/09/25
Tab. Pan40 mg1-0-0Before food15 days
Tab. Becadexamine1 tab1-0-0After food30 days

Discussion

Clinical Presentation

The patient’s symptoms of giddiness, unsteadiness of gait, lower limb numbness, and diplopia are indicative of CNS involvement. These symptoms, along with the chronicity of diplopia, suggest a relapsing-remitting course of MS.

Diagnostic Criteria

The McDonald criteria for MS diagnosis require evidence of dissemination in space and time. MRI findings in this patient demonstrate lesions in multiple CNS regions, fulfilling the dissemination in space criterion. The temporal separation of symptoms supports dissemination in time.

Role of MRI

MRI is the gold standard for diagnosing MS, as it can detect lesions in the CNS that correspond to areas of demyelination. T2/FLAIR hyperintense lesions are characteristic of MS and are commonly found in the periventricular white matter, brainstem, and spinal cord. The presence of cervical cord expansion in this patient further supports the diagnosis.

Cerebrospinal Fluid Analysis

CSF analysis in MS typically reveals normal protein levels, normal or mildly elevated white blood cell count, and the presence of oligoclonal bands. In this patient, the normal protein level and absence of oligo-clonal bands do not exclude the diagnosis but may suggest a less active course.

Differential Diagnosis

The negative NMO/MOG antibody tests help exclude neuromyelitis Optica spectrum disorders and myelin oligodendrocyte glycoprotein antibody-associated disease, which can present similar symptoms and MRI findings.

Treatment

High-dose intravenous corticosteroids are the mainstay of treatment for acute relapses in MS. They reduce inflammation and shorten the duration of symptoms. The patient also started on a tapering dose of oral corticosteroids to prevent relapses and manage inflammation.

ClassExampleMechanism
Interferon-βIFN-β-1a, IFN-β-1bDownregulates proinflammatory cytokines
α4-integrin blockerNatalizumabInhibits leukocyte migration across BBB
Anti-CD20 monoclonal antibodyOcrelizumabDepletes B cells
Synthetic myelin-mimicking polypeptideGlatiramer acetateInduces Th2 tolerance
Nrf2 activatorDimethyl fumarateActivates Nrf2 pathway and reduces oxidative stress

Prognosis and Follow-Up

The prognosis in MS varies depending on the subtype and disease course. Relapsing-remitting MS, the most common form, often has a favorable prognosis with appropriate treatment. Regular follow-up with neurological assessments and MRI scans is essential to monitor disease progression and adjust treatment as needed.

Conclusion

This case highlights the classical presentation of Multiple sclerosis in young female, demonstrating hallmark clinical, radiological, and CSF features. Early recognition and exclusion of mimics are critical for timely management. While corticosteroids remain the cornerstone for acute attacks, enhanced access to DMTs and better awareness are essential to reduce long term disability and improve quality of life.

References

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