Multiple sclerosis (MS) is a chronic demyelinating disease of the CNS with relapsing-remitting episodes. Patients with MS often present to the ED with new neurological symptoms. For rookies, the challenge is distinguishing an acute MS exacerbation from other mimics and knowing when to initiate therapy versus when to defer to neurology.
What Is an MS Exacerbation?
- New or worsening neurological symptoms lasting >24 hours.
- Not explained by fever, infection, or metabolic disturbance.
- Caused by inflammatory demyelination in CNS.
Common Presentations
- Visual: optic neuritis → painful vision loss, decreased color vision.
- Motor: limb weakness, spasticity.
- Sensory: numbness, tingling, Lhermitte’s sign (electric-shock sensation with neck flexion).
- Cerebellar: ataxia, tremor, vertigo.
- Bladder/bowel dysfunction.
Rookie pearl: UTI or fever can cause “pseudo-relapse” — old deficits worsen temporarily without new demyelination.
Step 1: Rule Out Mimics
- Check for infection: UTI, pneumonia, viral illness → common triggers.
- Check electrolytes, glucose — metabolic disturbances worsen MS symptoms.
- Review medications, compliance with disease-modifying therapies.
Step 2: Initial ED Workup
- Full neuro exam, document new deficits.
- Labs: CBC, electrolytes, UA, cultures if febrile.
- Consider MRI brain/spine (if available and safe) to confirm new lesions.
- Exclude stroke if acute focal deficits — CT/CTA may be necessary.
Step 3: Treatment in the ED
- High-dose IV steroids = mainstay.
- Methylprednisolone 1 g IV daily × 3–5 days.
- Reduces inflammation, shortens relapse duration.
- If steroids contraindicated (uncontrolled diabetes, infection not excluded) → consult neurology before starting.
- Pain, spasm, and symptom management (NSAIDs, muscle relaxants, bladder support).
Step 4: Refractory Cases
- If no improvement after steroids → plasmapheresis may be considered (neurology/ICU decision).
- IVIG sometimes used as alternative.
Step 5: Disposition
- Admit if:
- Severe relapse (e.g., profound weakness, vision loss, brainstem involvement).
- Concern for infection or diagnostic uncertainty.
- Patient cannot manage safely at home.
- Discharge if:
- Mild relapse, reliable follow-up, outpatient steroids possible.
Common Rookie Mistakes
- Treating pseudo-relapse (infection, fever) with steroids → worsens underlying infection.
- Forgetting to screen for UTI in MS patients with worsening neuro symptoms.
- Starting steroids before excluding other causes of acute neuro deficit (like stroke).
- Not documenting neuro exam carefully — essential for follow-up.
Rookie Pearls
- Always rule out infection first before calling it a relapse.
- If unsure, involve neurology early — treatment is time-sensitive but nuanced.
- Steroids shorten relapse but don’t change long-term disease course — educate patients.
- Admit severe relapses — safe observation is better than risky discharge.
Take-Home Message
For rookies:
- MS exacerbation = new neuro deficit >24 hrs, not explained by infection/metabolic issues.
- Rule out pseudo-relapse with basic labs and infection screen.
- Treat with IV methylprednisolone once safe.
- Admit if severe, unclear, or unsafe for discharge.
Remember: In MS patients, always check for infection before reaching for steroids.
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