Elizabeth, 28, is referred by her family practitioner with a note that her MRI report is suggestive of MS. She is married with two children and is currently employed as a middle school teacher. She has a history of episodic migraine but is otherwise healthy. She reports no neurological symptoms. There is no history of recreational drug use. There is no family history of demyelinating diseases including MS. Elizabeth tells you she has a maternal aunt with fibromyalgia.

The neurological examination is normal. A non-contrast MRI brain shows approximately 15 T2 hyperintense lesions: four periventricular, two juxtacortical, two in the corpus callosum, one in the middle cerebellar peduncle and the rest in the subcortical white matter.

Case 3 – Survey

Question 1: What is your clinical impression and plan? (pick 1)

Question 2: An MRI brain with contrast obtained six months later shows two gadolinium-enhancing lesions and one new T2 lesion; MRI spinal cord shows two short-segment eccentrically located lesions in the posterior cervical cord. During this time period, Elizabeth reports experiencing occasional migraines but no other neurological symptoms. The neuro exam remains normal. What is your diagnosis and plan? (pick 1)

Question 3: Six months later, non-contrast MRI brain shows three new T2 lesions. CSF shows 12 cells/HPF (all lymphocytes); positive OCB and increased IgG index; normal protein and glucose. Elizabeth reports a migraine one month ago but no neurological symptoms. The neuro exam is normal. What is your diagnosis and plan? (pick 1)

Question 4: What would you estimate to be Elizabeth’s risk of conversion to definite MS over the next five years? (pick 1)

Question 5: What are the factors that increase the odds of conversion to definite MS in patients with RIS? (pick your top 3)



Click here to watch Dr. Courtney Casserly discuss the case and the responses to the survey.

Jim is a 26-year-old firefighter who presents with an episode of mild leg weakness, sensory level at T6 and moderate bladder symptoms.

At presentation his EDSS score is 3.0, with leg weakness, spasticity and sensory changes. Baseline brain MRI reveals several (10) lesions including brain and brainstem. Spinal MRI shows a gadolinium-enhancing lesion at T2, and another lesion which does not enhance at C3.

He is treated with steroids with a good response. Serum is negative for anti-AQP4 antibodies and anti-MOG antibodies, and CSF is positive for oligoclonal banding. All other preliminary investigations are unremarkable and the MRI looks characteristic for multiple sclerosis.

At 3-month follow-up, Jim still has sensory and bladder symptoms. EDSS score is 2.0 (sensory 2, bowel 1, bladder 1).

The survey is now closed. We received 26 responses. See below for a summary of the answers you provided.

Question 1: Do you consider Jim to have aggressive RRMS?
Most respondents (82%) considered Jim to have aggressive RRMS due to a significant motor relapse with incomplete recovery and MRI lesions in the brain and spinal cord.

Question 2: What feature in this case do you find most worrisome?
The most worrisome feature was early disability (EDSS 3.0) (36% of responses) and the presence of spinal cord lesions (36%).

Question 3: In general, what clinical/radiological finding would be most likely to prompt you to initiate treatment with a higher-efficacy DMT?
The most common reasons cited for starting with a higher-efficacy DMT were ≥ 2 relapses in the previous year (27%), high T2 burden of disease (14%) and incomplete recovery at 3-6 months (14%).

Question 4: What would be your preferred starting therapy for this patient?
The preferred starting treatment was an anti-CD20 agent, such as ocrelizumab (55%) or ofatumumab (32%). Some respondents selected natalizumab (9%) or cladribine (5%).

Question 5: Despite counselling, Jim refuses to receive the COVID-19 vaccine. What would be your preferred starting therapy now?
There was a substantial shift away from anti-CD20 therapies in a COVID-19 vaccine refuser. The preferred starting therapy in these circumstances was natalizumab (32%), followed by ocrelizumab (27%) and ofatumumab (14%). A total of 14% of respondents opted for a platform therapy (DMF or glatiramer acetate).

View the video commentary by Dr. Courtney Casserly.



CLINICAL CASES IN MS – CASE 1: Neurological symptoms after COVID-19 vaccination


Watch Dr. Daniel Selchen as he shares his thoughts about this case.

Linda H., 48, is a partner at an accountancy firm, married with no children. She presents with paresthesiae following vaccination for COVID-19. She has no history of medical or neurological conditions and no pertinent family history.

Two weeks after receiving a first dose of the BNT162b2 (Pfizer-BioNTech) mRNA vaccine, Linda noticed a loss of sensation around her right breast, with subsequent paresthesiae of the right leg and left leg. Symptoms evolved over 1 week. There was no motor involvement. The patient was afebrile. She reported no bladder or systemic symptoms. Paresthesiae resolved after 5-6 weeks without treatment.

C-spine MRI revealed 1 lesion at C7-T1, right posterior; the lesion crossed the midline with some gadolinium enhancement. There was no longitudinal extension of the lesion. A subsequent brain MRI (without Gd) showed multiple deep hyperintense T2 lesions; 2 of the lesions abutted the corpus callosum.

The survey is now closed. We received 52 responses. See below for a summary of the answers you provided.

Question 1: Do you believe that COVID-19 vaccination…
A majority (51%) believed that vaccination may have unmasked a previously undiagnosed MS. Some believed that vaccination was unrelated to current neurological symptoms (19%), and some that vaccination may have triggered an autoimmune response (17%).

Question 2: Would you recommend that Linda not receive a second COVID-19 vaccination?
A majority (50%) would recommend delaying a second vaccination until a further work-up can be done, although many (35%) felt that a second dose should be advised since it would be unlikely to worsen neurological symptoms.

Question 3: What further investigations would you perform?
This question allowed for multiple investigations. The most common investigations selected were CSF for oligoclonal banding (67%); a broad autoimmune work-up (58%); MRI brain/C-spine in 3 months (56%); and MRI brain with Gd as soon as possible (52%).

Question 4: What is your diagnosis?
The most common diagnoses were CIS (48%) and RRMS (35%). A total of 8% believed the only diagnosis was COVID-19.

Question 5: What would be your preferred starting treatment for this patient?
A majority (57%) would not start treatment at this time. Some respondents would start with dimethyl fumarate (14%), teriflunomide (8%), glatiramer acetate (6%), an interferon-β (6%), ocrelizumab (4%) or ofatumumab (2%).

View the video commentary by Dr. Daniel Selchen: