Review Question - QID 110012

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Multiple Sclerosis Presentation Symptoms - may have multiple neurologic symptoms separated in time and space QID: 110012 (M1.NE.17.4884)

QID 110012 (Type "110012" in App Search)

A 32-year-old man presents to his primary care provider with right leg weakness and numbness. He reports a 2-day history of “clumsiness” in his right lower extremity after playing in his company’s annual weekend-long charity baseball tournament. He says a similar episode happened 1 year ago during the same tournament. He has a history of major depressive disorder and right distal radius fracture status post-closed reduction and casting after falling 2 years ago. He takes fluoxetine. He also reports that he several years ago he had an isolated episode of decreased vision and inability to move his right eye that resolved on its own. He has a 15-pack-year smoking history and drinks 3-4 beers per week. His temperature is 98.4°F (36.9°C), blood pressure is 115/65 mmHg, pulse is 85/min, and respirations are 18/min. On exam, hip flexion, knee extension, and ankle dorsiflexion are all 3/5 on his right and 5/5 on his left. Right Achilles and patellar reflexes are 1+ on the right and 2+ on the left. He has decreased sensation to light touch throughout the right leg especially below the knee. Additional questioning would most likely reveal which of the following additional features about this patient’s current symptoms?

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Concomitant hyperreflexia

18%

24/130

Symptom improvement in the heat

6/130

Symptom exacerbation in the heat

38%

50/130

Symptom exacerbation with repetitive muscle contractions

24%

31/130

Symptom improvement with repetitive muscle contractions

9/130

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The patient in this vignette presents with unilateral lower extremity numbness and weakness with a history of similar prior episodes suggestive of a multiple sclerosis (MS) flare. MS symptoms can often be exacerbated in the heat.

MS is an autoimmune demyelinating disorder characterized by acute episodes of lower or upper motor neuron dysfunction. Symptom exacerbation in heat is characteristic of MS symptoms. This is known as Uhthoff phenomenon and is hypothesized to stem from the inhibitory effects of heat on nerve conduction. Settings associated with Uhthoff pheonomenon include hot weather, saunas, hot tubs, rigorous exercise, and fever.

Incorrect Answers:
Answer 1: Concomitant hyperreflexia and/or hypertonicity would not necessarily be present in this patient unless upper motor nerves were also affected in this acute flare. Concomitant upper and lower motor neuron dysfunction is seen in amyotrophic lateral sclerosis which typically presents later in life and is characterized by progressive worsening rather than discrete episodes.

Answer 2: Symptom improvement in the heat would not be seen in MS as symptoms worsen in heat.

Answer 4: Symptom exacerbation with repetitive muscle contractions is characteristic of myasthenia gravis. In this condition, autoantibodies directed against the post-synaptic acetylcholine receptor lead to weakness that gets worse with repetitive muscle contraction.

Answer 5: Symptom improvement with repetitive muscle contractions is characteristic of Lambert-Eaton myasthenic syndrome (LEMS). In this condition, autoantibodies directed against the pre-synaptic voltage-gated calcium channel lead to weakness that gets better with repetitive muscle contraction.

Bullet Summary:
Symptom exacerbation in heat (Uhthoff phenomenon) is characteristic of multiple sclerosis.

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