Age: 29.0
Sex: F
Vaccine: HEP
Symptoms: Hypoaesthesia, Multiple sclerosis, Optic neuritis, Visual disturbance
Clinical narrative: In January 1996 - the patient had visual disturbances of the left eye, resolved on it's own. In Sept & Oct. of 1996 - the patient had leg numbness, feelings of "pins & needles"; resolved after 4 months. In March 2000 - The patient's left eye, same visual disturbance, optic neuritis, MS. High dose of steroids, MRI, Copaxine.  Follow up received on 5/21/01 states, "she has headaches which are mostly eye strain, muscle tension headaches. No dizziness, loss of consciousness, trouble with speech or memory. No nausea, vomiting, loss of taste or smell sensation. She still has poor vision in the left eye with difficulty identifying shapea, figures, colors. She is also very photosensitive in this eye. No diplopia. No facial numbness or tingling. No difficulty chewing or swallowing. No hearing loss, tinnitus or vertigo. No lateralzing weakness. She has mild numbness on the  medial side of her left foot, which is intermittent. No other sensory symptoms. No difficulty with balance, coordination or gait. No sphincteric inconstinence. No history of head, neck or low back injury. No cardiopulmonary, gastrointestinal or genitourinary symptoms. Negative for mitral valve prolapse, rheumatic fever, coronary artery disease, cardiac arrhythmias, hypertension, COPD, asthma, anemia, diabetes, thyroid, liver or renal disease. No hitory for migraines, seizures or strokes. Impression: mild early stage of multiple sclerosis. History of optic neuritic twice in teh elft eye. Clinically stable. Currently eight months pregnant. After she delivers and finished nursing, she can start the Copaxone 20mg subq qd. I will see her back in follow-up in six months or earlier if needed." Follow up received on 5/21/01 states "pt was seen for neuro-ophthalmic evaluation on 3/16/00 at your request. This young woman has a history that dates back approximately two years when she had her first episode of visual loss in the left eye. At that time, she stated that she had a gradual onset of visual loss over a month that was painless and had no pain in eye movement according to her. I do not know if she sought medical attention, but she certainly did not get any treatment and had no workup for this. She stated her vision; however, eventually improved. It probably went back to normal. Sometime after that, and I am not sure exactly when, whether it was soon after or months afterwards, she experiecned numbness in the anterior and posterior bilateral thighs. She and others, she said, attributed the numbness to a vigorous exercise program. It, however, resolved after two months. She has not had any other common neurological problems until January of 2000 when she began to experience a gradual visual loss in the left eye over three weeks. She had pain in eye movement. When you saw her, your note states she was 20/25 in that eye with only slight temporal pallor. Her vision hasa now worsened over the last day to no light perception. No family history of any significant neurological problems according to her. On today's evaluation, she is 20/15 OD and no light perception OS. She has a normal threshold field in the right eye and normal anterior segment exam. Intraocular pressure are 15 in both eyes. There is no ptosis nor proptosis. No inject ? the conjunctivae and sclerae. The pupils are 6mm, round and reactive to light with an amaurotic pupil in the left eye. Examination of the extraocular eye muscles revealed full versions, smooth pursuit without nystagmus and rapid saccades. Funduscopy of the right eye demonstrates a ? disc, macular, retina, and vessels with 0.2 cupsl The left eye? light disc with severe diffuse loss of nerve fiber later, intact macula, retina and vessels. Neurologically, she has an intact mental status. Her cranial nerves are really otherwise normal. Her gait and tandem are normal. Her tanem stance with her eyes closed is normal for 30 seconds. Rapid finger movements, finger-to-finger-to-nose testing, and upper extremity strenght are normal. Reflexes are 1-2+ in the uper and lower extremities, and the toes are downgoing. The Romberg is negative. Vibration sensation in the toes is normal. This is an unusual presentation of recurent optic neuropathy. It sounds like in her age group an optic neuritis. I say this because I believe that episode of numbness that she had in the upper legs was not, of course, a nerve root or local muscle problem but an episode of demyelinating disease probably of the spinal cord. Because of this, she has had an MRI ordered otday with the suspicion that she has optic neuritis recurrent and MS. I am bothered by the fact that, however, the first episode did not have pain in eye movement, and she said it was a gradual loss over the course of four weeks which is a little bit atypical but again, we have no documentation of this. In any event, an MRI scan was ordered, and, indeed, she has multiple brain UBOs on FLAIR and T2-weighted images, and she has slight but definite enhancement of the intracanalicular portion of the optic nerve with gadolinium. I have discussed these issues with her and her husband and she is set up for homecare IV for three days followed by a week or tend ays or oral prednisone. I think that she will be a good candidate to place on Avonex because, indeed, I do believe she has MS."