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J.T. is a 42-year-old woman previously well except for frequent urinary tract infections, which included an episode of pyelonephritis with no known anatomical abnormality. She initially presented with two relapses about six months apart, a mild optic neuritis and a mild sensory myelopathy with excellent spontaneous recovery. Her EDSS score was 1.0. She was started on dimethyl fumarate.
Seven months later she came to the emergency room with a severe relapse with multifocal findings including diplopia, severe ataxia, weakness, mixed ataxic and pyramidal gait disturbance. Her EDSS score was 6.0. MRI revealed multiple infra- and supratentorial enhancing lesions. She was treated with intravenous steroids with gradual improvement to an EDSS of 4.0.
Workup for treatment escalation revealed that she was non-immune to varicella, had a serum IgG level of 5.98 g/L (lab normal range approx. 6-16 g/L), a lymphocyte count of 0.8 x 109/L, and a JCV index of 2.89.