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Recurrent Demyelinating Episodes

A 28-year-old woman with a history of migraine, type 2 diabetes, irritable bowel syndrome, and mild anxiety sought care for right monocular painful vision loss presenting over 3 days. Two years earlier, she had had back paresthesias for 1 week which were triggered by flexion of the neck suggestive of Lhermitte sign. She also reported intermittent bilateral arm paresthesias for 2 years. She had almost daily headaches, treated with naproxen daily. She reported no bladder, bowel, or sexual dysfunction or episodes of vertigo, diplopia, or unexplained nausea, vomiting, or hiccups.
 Magnetic resonance imaging of the brain revealed multifocal T2 fluid-attenuated inversion recovery white matter hyperintensities throughout the brainstem, cerebellum, and bilateral periventricular, subcortical, and juxtacortical areas. Magnetic resonance imaging of the cervical and thoracic spinal cord showed intramedullary cord signal T2 hyperintensities peripherally located at C1 and on the left side at C3-C4.
 The patient was diagnosed with relapsing-remitting multiple sclerosis with activity on the basis of her clinical presentation and magnetic resonance imaging findings.
 She received comprehensive education about the disease and the role of disease-modifying therapy to decrease the risk of further clinical and radiographic activity. After discussion of the risks and benefits of the various agents, the patient started treatment with dimethyl fumarate. Oral vitamin D3 supplementation was recommended. Healthy lifestyle changes, including maintaining a healthy diet, normal weight range, regular exercise, and sleep hygiene were recommended.
 Disease-modifying therapies for relapsing-remitting multiple sclerosis are primarily used to reduce the occurrence of clinical relapses and the appearance of new T2 or enhancing lesions on magnetic resonance imaging of the brain and spine. Long-term treatment with disease-modifying therapy is associated with lower morbidity and mortality rates.