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Joseph is a 28-year-old shipping manager at a local warehouse. He is married and has a three-year-old daughter. He presents in April 2021 following an episode of right sided vision loss, with minimal pain. Exam showed visual acuity 20/400, loss of colour vision and an afferent pupillary defect. The rest of his neuro exam is normal. Brain MRI revealed MS-like white-matter abnormalities with a moderate burden of disease and evidence of right optic neuritis (T2 hyperintensity and contrast enhancement). He was treated with IVMP 1000 mg daily x 3 days, with minimal improvement. There is no history of comorbid conditions and no family history of demyelinating or autoimmune disorders. He has not received a COVID-19 vaccine. Extensive discussion does not change his mind and he says he has no plans to get vaccinated.


Question 1: What is your provisional diagnosis?

Question 2: What additional tests would you obtain? (max. 3 choices)

Question 3: Would you initiate treatment with a disease-modifying therapy (DMT) at this time?

Question 4: He develops interscapular pain, numbness/weakness in both legs, is unable to walk and has urinary urgency/incontinence.Moderate paraparesis, sensory level at T6, hyper-reflexia, bilateral Babinski sign.Hospitalized with thoracic myelopathy.MRI spine: 2.5-segment enhancing lesion at T4. CSF: 39 WBCs, mainly lymphocytes.OCB pattern atypical, 1 band (not in serum).Negative for NMO and MOG Ab. JCV index negative.Partial recovery with IVMP 1000 mg x5 d; able to walk but not run. How would you treat?

Question 5: How does Joseph’s COVID-19 vaccination status influence your treatment decision?

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