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)

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