Click here to watch Dr. Lisa Sabella discuss the case and the responses to the survey.

R.M. is a 24-year-old woman who works at a daycare centre. She is referred from the emergency room because of a two-week history of paresthesiae in both legs and the mid and lower trunk. She is not aware of any weakness. There is no bladder disturbance. She has a subjective mid truncal sensory level. Prior history includes a Bell’s palsy three years ago which was painless and resolved without treatment in 3-4 weeks.

On examination she has pallor of the left optic disc with intact vision. There is no abnormality of extraocular movements and no residual facial weakness. There is no objective sensory level. She has mild loss of distal vibration at the great toes. She has a left extensor plantar. EDSS is 1.5. MRI of the spine shows a non-enhancing short segment lesion laterally at C3 and an enhancing short segment posterior lesion at T3.

Subsequent MRI of the brain shows four characteristic supratentorial lesions, a mid pontine lesion, and a cerebellar peduncle lesion. None of the brain lesions enhance. Her symptoms resolve completely in five weeks with no treatment. Repeat examination is unchanged. Routine blood work is unremarkable. She is non-immune to measles and hepatitis B.

The survey is now closed. There were 42 responses. See below for a summary of the answers you provided.

Question 1: What is your diagnosis?
A majority of respondents (85.7%) agreed that this patient met the diagnostic criteria for multiple sclerosis. About 5% opted for a MOG antibody disease diagnosis and about 10% were unsure.

Question 2. What additional tests would you obtain?
Most respondents (52.4%) said no further tests were necessary. The remaining respondents said they would obtain OCBs (28.6%), NMO and MOG antibodies (14.3%) or serum NfL (4.7%).

Question 3. Does she need vaccination pretreatment?
Respondents were equally divided between Yes (42.9%) and Depends on the treatment (42.9%). About 14% said she does not need vaccination.

Question 4. Would you initiate a disease-modifying therapy now?
Most respondents (57.1%) said Yes. However, 23.8% would await vaccination and 19.1% said they would await further test results. No one opted for watchful waiting until the next relapse/MRI lesion.

Question 5. What is your treatment recommendation?
A majority of respondents (71.4%) said they would start treatment with an anti-CD20 agent. Another 9.5% would select oral cladribine. A small proportion of respondents (4.8%) said they would start treatment with a platform injectable, DMT or teriflunomide.

View the video commentary from Dr. Lisa Sabella.