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Dexamethasone
26%
30/116
Methotrexate
20%
23/116
Natalizumab
14%
16/116
Infliximab
16%
18/116
Adalimumab
1%
1/116
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This young female presenting with sudden loss of vision, difficulty speaking, and a history of a similar episode 2 years ago is most concerning for multiple sclerosis (MS). Natalizumab prevents progression of symptoms and is used in long-term management. MS is an autoimmune demyelinating disorder of the central nervous system. Charcot’s neurologic triad includes scanning speech, intention tremor (internuclear ophthalmoplegia and incontinence), and nystagmus. (Remember MS is a SIN). Swinging light test indicates an afferent pupillary defect on the left, consistent with damage to the optic nerve. This diagnosis is confirmed by MRI, which is the gold standard for diagnosis and commonly shows enhancing lesions and periventricular plaques, also known as Dawson’s fingers. Natalizumab is a monoclonal antibody that targets alpha-4 integrin. It is used to slow progression of MS. There is an increased risk of progressive multifocal leukoencephalopathy and all patients should be tested for JC virus prior to initiation. Illustration A demonstrates the periventricular lesions that are commonly seen in patients with multiple sclerosis. These lesions may be described as Dawson's fingers. Incorrect Answers: Answer 1: Dexamethasone will speed recovery of ocular symptoms but does not change the overall progression of the disease. Answer 2: Methotrexate is a dihydrofolate reductase inhibitor thus inhibiting DNA and RNA synthesis. It is often used to treat rheumatoid arthritis and in certain malignancies. It would not be used to treat acute flares in a patient with multiple sclerosis. Answer 4: Infliximab is a monoclonal antibody that targets TNF-alpha. It is used to treat a number of autoimmune disorders including rheumatoid arthritis and psoriasis. Answer 5: Adalimumab is a TNF-alpha inhibitor commonly used to treat rheumatoid arthritis, Crohn's disease, ulcerative colitis, and other autoimmune diseases. It is not used in the treatment of MS Bullet Summary: Natalizumab is a monoclonal antibody that is used to slow progression of MS.
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