Multiple Sclerosis: A 40-Year-Old Woman With Newly Diagnosed MS

Hesham Abboud, MD, PhD | Director, Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio

A 40-year-old woman presents to your clinic with right lower extremity weakness and numbness. She had a history significant for uncontrolled type 2 diabetes and hypertension. She had had a transient episode of double vision and nonpositional vertigo 2 years prior to presentation that had improved spontaneously.

A magnetic resonance imaging (MRI) scan of her thoracic spine showed an enhancing, short-segment, demyelinating lesion at the T4 vertebral level . A brain MRI scan showed nonenhancing, demyelinating lesions periventricular and pontine in location. Her symptoms of weakness and numbness improved partially with high-dose corticosteroids.

Serum test results were positive for the human polyomavirus 2 antibody. She is not vaccinated against COVID-19.