A young female w/ hypothyroidism presents with 3 days of paresthesias and gait instability. She notes similar R hand numbness one month ago that resolved spontaneously. MRI showed 2 enhancing lesions in the dorsal column c/w MS, and IV solumedrol was initiated in the hospital with the plan for an outpatient steroid taper.
*What is most high yield in a sensory exam?
-Light touch is hard to test, but running a pointed object from foot to thigh may help detect stocking/glove neuropathies
-Patients with a dorsal column lesion (i.e. B12, MS) have a disproportionate loss of vibration and proprioception (compared with pain and temperature), so it is important to test more than just light touch.
*When should steroids be given for an MS flare?
-Steroids can hasten recovery of acute exacerbations but may not change the extent of recovery
–Steroids should ALWAYS be given if symptoms affect vision, strength or cerebellar function. They may be given for other isolated symptoms (ie paresthesias) IF symptoms are especially bothersome.
-While IV steroids are often given during an acute flare, oral prednisone or methylprednisolone can be used for the taper.
*Oligoclonal what? (Protein-related terms you often hear when talking about CSF)
-Albuminocytologic dissociation: elevation in CSF protein without an elevation in white blood cells. This is thought to be inflammation of the nerve roots. Most CNS protein is usually albumin. Classic textbook association is with AIDP (a.k.a Guillain-Barre).
-Oligoclonal bands: immunoglobulins are usually excluded from CSF. “Oligoclonal bands” refers to immunoglobulins in the CSF that exhibit bands on protein electrophoresis. This indicates inflammation of the CNS. Textbook association is with multiple sclerosis and can be considered as part of the diagnosis, but it is nonspecific and other conditions can cause this.