Multiple sclerosis: The Daily PANCE Blueprint
A 42-year-old man presents with a 2-year history of gradually worsening leg stiffness and balance difficulties. He reports that his symptoms have progressed steadily since onset without clear attacks or remissions. Over the past 6 months, he has required a cane to walk safely due to worsening mobility. On examination, he has spastic paraparesis and impaired tandem gait. MRI of the brain and cervical spine shows multiple periventricular and juxtacortical T2 hyperintensities consistent with demyelination. Lumbar puncture is positive for oligoclonal bands. What is the most likely subtype of multiple sclerosis in this patient?
A. Relapsing-Remitting MS
B. Primary Progressive MS
C. Secondary Progressive MS
D. Clinically Isolated Syndrome
E. Progressive-Relapsing MS
Answer and topic summary
The answer is B. Primary Progressive MS
The patient’s symptoms of a 2-year history of gradually worsening leg stiffness, balance difficulties, and the need for a cane, along with MRI and lumbar puncture findings, are indicative of primary progressive MS. This subtype is characterized by a gradual accumulation of disability without clear attacks or remissions. Approximately 10 to 15 percent of patients with MS present with this pattern, which aligns with the patient’s clinical presentation.
Incorrect Answers:
- A. Relapsing-Remitting MS: This subtype involves acute episodes of neurologic dysfunction, not a gradual accumulation of disability.
- C. Secondary Progressive MS: This subtype usually follows a period of relapsing-remitting MS and is not typically the initial presentation.
- D. Clinically Isolated Syndrome: This refers to a monosymptomatic attack that does not fulfill diagnostic criteria for MS but may predispose to clinically definite MS.
- E. Progressive-Relapsing MS: This is a rare subtype that involves a progressive course with superimposed relapses, not typically the initial presentation.
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Also covered as part of the Internal Medicine EOR topic list
