The case is a 24 y/o woman with early multiple sclerosis. Should she have disease monitoring therapy, or alternatively, monitoring only. Either answer has an expert to argue for it. A reader poll split close to 50/50. https://www.nejm.org/doi/full/10.1056/NEJMclde2300812?
In this example, I will give the GPT4 essay first. Then, I will show the NEJM case for which we see the GPT4 answer. The original case includes two alternate expert answers.
GPT4 ANSWER
This case presents a 24-year-old woman with blurred vision, pain on eye movement, and a magnetic resonance imaging (MRI) finding suggestive of retrobulbar optic neuritis, without any symptoms or lab findings definitively indicative of multiple sclerosis (MS).
This puts us in a situation where we have to balance the potential benefits of early intervention in a disease like MS against the risks of treatment in a patient whose diagnosis is not certain.
Option One: Initiation of Disease-Modifying Therapies for Multiple Sclerosis
There are several reasons to consider initiating disease-modifying therapy (DMT) in this patient. Optic neuritis is often one of the first symptoms of MS, and the presence of a lesion in the periventricular white matter is a strong indicator of demyelinating disease, even though there is only a single lesion. Early initiation of DMT in MS has been associated with better long-term outcomes, including reduced disability and delayed progression of disease.
Given that MS is a chronic and progressive disease, timely intervention can potentially prevent irreversible neuronal damage. DMTs for MS, including interferon beta, glatiramer acetate, fingolimod, and others, have been shown to reduce the frequency of relapses and slow the progression of disability. The cost of these therapies and potential side effects, such as flu-like symptoms, injection site reactions, and rare but serious risks such as progressive multifocal leukoencephalopathy with some agents, would need to be carefully discussed with the patient.
This approach aligns with an aggressive management strategy. It is based on the principle of 'treat early and treat effectively' to prevent irreversible neurologic damage.
Option Two: Recommend Monitoring Only At This Time
The second option is to recommend close monitoring at this time without initiation of disease-modifying therapies. This approach would involve regular clinical follow-ups and repeated imaging to look for new lesions or changes in existing ones.
One argument in favor of this approach is the fact that the patient's diagnosis is not certain. Although her symptoms and MRI findings are suggestive of MS, they do not meet the McDonald Criteria for MS, which would require at least two separate episodes of symptoms or evidence of at least two lesions in specific areas of the central nervous system. There are also no oligoclonal bands in the CSF, and the anti-AQP4 and anti-MOG antibodies are negative.
DMTs are not benign drugs. They come with risks of adverse effects and a significant cost. Starting a patient on these medications prematurely, particularly when the diagnosis is not definitive, may expose her to unnecessary risks.
The downside to the monitoring approach is that it may delay treatment if the patient does indeed have MS, potentially resulting in additional neurological damage.
Overall, this case presents a difficult decision that needs to be individualized based on the patient's preferences, concerns about the risks and benefits of starting treatment, and the physician's clinical judgement. It would also be useful to get a neurologist involved in this patient's care, given the potential for a diagnosis of MS.
ORIGINAL NEJM CASE STUDY
Case Vignette
A 24-Year-Old Woman with Blurred Vision
Clement D. Lee, M.D.
A 24-year-old woman presents to the emergency department with blurred vision that has developed in the past few days. Symptoms are worse with her left eye closed, and her vision normalizes when her right eye is closed. She has pain, mainly in the right globe, with movement of her eyes. She has no history of medical problems and takes no medications; no myopia, hyperopia, or astigmatism was noted at her last optometric assessment a year ago. She reports no history of or current double vision, difficulty in speaking, weakness, tremor, urinary incontinence, or abnormal spinal sensations. There is no family history of neurologic or ophthalmologic disease.
Examination shows visual acuity of 20/60 in the right eye and 20/20 in the left eye and normal extraocular movements, without nystagmus. A relative afferent pupillary defect (in which a light shone in one eye results in less pupillary constriction than light shone in the other eye) is present on the right side, and the patient is unable to identify 9 of the 10 numbers on Ishihara plates (a test of red–green color discrimination) with the right eye. Dilated funduscopy shows normal optic disks in both eyes. T2-weighted magnetic resonance imaging (MRI) of the optic nerves, brain, and entire spinal cord, performed with the administration of gadolinium, shows enhancement of the right optic nerve with optic-nerve swelling, a finding consistent with retrobulbar optic neuritis. A single, small, nonenhancing ovoid lesion is also noted in the periventricular white matter without surrounding edema. The patient undergoes lumbar puncture, and intravenous glucocorticoids are administered.
Routine laboratory studies are normal. There are no oligoclonal bands in the cerebrospinal fluid (CSF), and testing for anti–aquaporin-4 (anti-AQP4) and anti–myelin oligodendrocyte glycoprotein (anti-MOG) antibodies in serum is negative.
As the admitting physician, in addition to treating her optic neuritis, you consider whether the patient’s symptoms and test results suggest the possible onset of multiple sclerosis. You must decide whether this patient should receive disease-modifying therapy for multiple sclerosis or whether monitoring alone is appropriate at this time.
Management Options
Which one of the following approaches would you take? Base your choice on the literature, your own experience, published guidelines, and other information.
Recommend initiation of disease-modifying therapies for multiple sclerosis.
Recommend monitoring only at this time.
