Multiple Sclerosis Flare due to UTI
Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.
A 35-year-old AAF with a PMH of MS is admitted with a chief complaint of generalized weakness and inability to walk. At baseline, she is able to transfer independently from a bed to a chair and to walk with assistance. Her PMH is positive for urinary incontinence and frequent UTIs that lead to MS flares. The current complaints are typical of her MS flares.
She also c/o nausea and has vomited in ER. She reports no abdominal pain or dysuria.
PMH
MS, treated with IVMP (IV methylprednisolone) every 2 months, each course consists of Solu-Medrol 1 gm over 30 min for 3 days. UTIs, urinary incontinence, presenile dementia, hypercholesterolemia.
Medications
Detrol, MVT.
Physical examination
VS 38.2-95-128/80-18 SpO2 98% on RA.
HEENT: dry MM, no nuchal rigidity.
Chest: CTA (B).
CVS: Clear S1S2.
Abdomen: Soft, NT, ND, +BS, wears a diaper.
Ext: no c/c/e.
Neuro: AAO x 3.
Strength 5/5 (B) UE, 0/5 RLE, 1/5 LLE, her baseline strength is 2/5 RLE, 4/5 LLE.
Sensation is intact, DTR are increased, and there is spasticity.
What is the most likely diagnosis?
MS exacerbation flare.
What is the reason for the MS flare in this patient?
It could be any infection, e.g. UTI or URTI. If it is summer, and there is no air conditioning in the patient's room, hot weather may be the reason for the MS flare.
What laboratory tests would you recommend?
CBCD, BMP
UA
BC x 2
CXR
What happened?
UA showed evidence of UTI.
WBC was elevated to 18.2 with 75% PMN.
BMP was WNL.
Ciprofloxacin 500 mg IV q 12 hr was started, along with NS at 150/hr for 2 L.
A neurology consult was called, and she recommended treating the UTI first, then reevaluating the patient to see if she needs IVMP.
The MRI showed chronic lesions of MS.
What happened next?
Solu-Medrol was started at 1000 mg IV q 24 hr x 3. The patient's condition improved significantly on the second day of IVMP treatment, with the recovery of her motor function to baseline, 4/5 LLE. She was discharged home with a prednisone taper, 40 mg PO qd x 5 d, 30 mg PO qd x 5 d, 20 mg PO qd x 5 d, then stop.
Final diagnosis
MS flare due to UTI.
What did we learn from this case?
Infections are a common reason for MS exacerbations. It is generally advisable to consult a neurologist early. Typically, MS patients are followed closely by their neurologist, and it is important to compare the current neurological complaints to their baseline status. Always ask if this attack is typical of their MS flares.
Consider interferon treatment, if recommended by the neurology consult.
References
Multiple Sclerosis. Merck Manual.
Multiple Sclerosis. The Cleveland Clinic.
UTIs May Trigger Relapse in Multiple Sclerosis. Journal of Urology, 1999.
Role of bacterial infection in exacerbation of multiple sclerosis. Am J Phys Med Rehabil, 1995.
Related reading
People with MS: Comedian Richard Pryor dies at 65. CNN, 12/05.
Published: 02/20/2006
Updated: 05/30/2009
Labels: Infectious Diseases, Neurology
5 Comments:
Thank you very much for this nice article.
What can we learn from this:
1-Is it a TRUE exacerbation? or
2-Is a Pseudo-exacerbation(Unthoff's phenomenon)due to UTI?
Pseudo-exacerbations are very common in Ms patients (especially when advanced), and usually wrongly diagnosed as true flare up. We dont know the type of MS she has.ie RRMS,PPMS...etc. The profound improvement of this davastating weakness after 1-2 days is more likely related to her UTI-induced pseudoexacerbation which was treated correctly. Besides, the MRI was done for what area(brain, cord)??, any how , it did not reveal any active lesion.
I think it is a Unthoff's pnenomenon (or syndrome) rather than a true flare up.
thank you
Hakim Raghig:
I agree .This is not a relapse.Relapse by definition would last at least 24 hours and you need at least one month as a time frame in between two different episodes.
You will also need dissemination in space and time according to Macdonald's criteria.
Thanks
To correct the comment on this case,
It is Schuber and Poser criteria that insist on dissemination in time and space.
McDonald (not MacDonald) criteria came out in 2001 and revised in 2005 has criteria for 1 attack, 1 lesion based on MRI.
Does the 35 yo in this case really have PMH of presenile dementia...is it iatrogenic (steroids)?
Consider adding more on latest treatments...
Thanks for correcting my spelling PGY3.
Who is Schuber ? Did you mean Schumacher ? Please let me know if there something called Schuber criteria that I am not aware of. Do you understand what is the meaning of dissemination in space and time? because based on your comment I do not think that you understand.You have to review the MacDonald criteria very carefully .What I was trying to say and may be I did not make it clear is If this patient carries a query diagnosis of MS,then that needs to be confirmed by this recent criteria.In case the diagnosis was really made according to this criteia , then we do not apply it on patients when they come with ? relapse.Just to remind you again that dissemination in space and time are the intergral part of McDnold criteria and I disagree with all of what you have said.Finally , how would 35 year old female get a presenile dementia? How common is that? and if that is the case do you have an evidenec that steroid on short term use may worsen the dementia?
Thanks
Dear Hakim and PGY3
McDonald criteria insists on dissemination intime and space in case of only one relapse. Both McDonald and Poser Criteria are useful for Diagnosis and has nothing to do with the diagnosis of remittance.
Dr. Eissa
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