Case Presentation: Patient A is a 59-year-old man with medical history of hypertension, asthma, benign prostate hyperplasia, daily marijuana use and occasional alcohol use who presented with acute onset of progressive weakness of his right upper extremity and right lower extremity. He had been assaulted to the face but denied any neck or back injury and then developed progressive right arm and leg weakness. He had a computed tomography of the head performed which showed round enhancing intramedullary lesion within the right hemicord of C2 with a larger area of surrounding non-enhancing cord signal abnormality concerning for active demyelination. Given these findings, neurology was consulted and he underwent a lumbar puncture, which showed cerebral spinal fluid positive for oligoclonal bands and elevated myelin basic protein. Serum NMP/AQP4 IgG, rapid plasma reagin (RPR) test, HIV and myelin oligodendrocyte glycoprotein (MGO) IgG were negative. He had a strong family history with a younger sister who was diagnosed with multiple sclerosis approximately 15 years ago when she was 43 years old. He has a niece, who was diagnosed with multiple sclerosis in her late teens or early 20s. Given workup and family history he was diagnosed with multiple sclerosis and started on high dose IV steroids for 5 days with an oral prednisone taper. He was also evaluated by physical therapy and occupational therapy and after initiation of steroid therapy his strength improved. He was discharged for follow up of multiple sclerosis with neurology as an outpatient. He was seen by his PCP one month after discharge from the hospital and had recovered most of his mobility.
Discussion: Multiple sclerosis (MS) is the most common immune-mediated inflammatory demyelinating disease of the central nervous system with a mean age of presentation of MS is 28-31 years old per multiple studies. It affects 900,000 people in the United States.The etiology of MS remains imperfectly understood and is multifactorial. Epidemiologic studies show links with MS to viral infections, geographic location, environmental exposures, and genetic predisposition. The virus most linked to MS is EBV, with one study citing a 32-fold increase in risk in MS after EBV exposure (1). There has also been a possible link between northern and southern latitudes with risk to MS (2), potentially attributable to less sunlight and vitamin D (3). As suggested by the case above, there seems to be a genetic predisposition to MS (4). There are over 200 genes that have been implicated as potentially contributing to MS (5). One study found that the relative lifetime risk of MS was increased by sevenfold among first-degree relatives (6). Strikingly, in a study comparing the prevalence of MS in twins, concordance rate increased from ~2-5% with dizygotic twins to ~25-30% with monozygotic twins (7).
Conclusions: In patients with acute paralysis, it is important to think about multiple sclerosis. This was a unique case due to acuity of the presentation and the patient was older than the usual presentation age of patients, and there was a strong family history. It is important to start treatment quickly in order to improve the prognosis of neurologic recovery.