What is the approach to diagnose a multiple sclerosis (MS) flare-up in the emergency department (ED)?

From the Guidelines

Diagnosing a multiple sclerosis flare-up in the emergency department requires a systematic approach combining clinical assessment, neurological examination, and appropriate diagnostic testing, with MRI with gadolinium contrast being the cornerstone diagnostic test. The first step is to obtain a detailed history focusing on the patient's established MS diagnosis, previous symptoms, and new or worsening neurological complaints 1. A thorough neurological examination should be performed to document objective findings consistent with new or worsening deficits. According to the 2019 guidelines, MRI studies should be of adequate quality, with few artefacts and performed on scanners with a minimum field strength of 1.5 T, and key MRI sequences include T2-weighted and T1 post-gadolinium images of the brain and the spinal cord 1.

Some key points to consider when interpreting MRI scans include:

• Lesions should be confirmed on multiple planes to avoid false positive findings due to artefacts and false negative results 1
• Serial imaging can support the diagnosis of multiple sclerosis, given that multiple sclerosis is characterized by the accrual of lesions over time and in new areas of the CNS 1
• Interpretation of the MRI scans should be performed by trained (neuro)radiologists or clinicians deeply familiar with the features of multiple sclerosis and disorders considered in the differential diagnosis 1
• For the diagnosis of multiple sclerosis, there should be at least one typical multiple sclerosis lesion in at least two characteristic regions [periventricular (abutting the lateral ventricles), juxtacortical, infratentorial, and spinal cord (cervical + thoracic)] 1

Laboratory tests including complete blood count, comprehensive metabolic panel, urinalysis, and sometimes cerebrospinal fluid analysis should be performed to rule out infection or other conditions that can mimic MS exacerbations. It's essential to exclude pseudoexacerbations, which are temporary worsening of symptoms due to fever, infection, stress, or heat exposure without actual disease progression. If a true MS flare is diagnosed, treatment typically involves high-dose corticosteroids such as methylprednisolone 1000mg IV daily for 3-5 days, sometimes followed by an oral prednisone taper. Coordination with the patient's neurologist is crucial for continuity of care and appropriate follow-up after ED management.

From the FDA Drug Label

In treatment of acute exacerbations of multiple sclerosis, daily doses of 160 mg of methylprednisolone for a week followed by 64 mg every other day for 1 month have been shown to be effective

The approach to diagnose a multiple sclerosis (MS) flare-up in the emergency department (ED) is not directly addressed in the provided drug label. However, it mentions the treatment of acute exacerbations of MS using methylprednisolone.

• Diagnosis of MS flare-up is not explicitly stated in the label.
• The label only provides information on the treatment of acute exacerbations of MS using methylprednisolone 2. The FDA drug label does not answer the question.

From the Research

Diagnosing MS Flare-Up in the ED

To diagnose a multiple sclerosis (MS) flare-up in the emergency department (ED), the following steps can be taken:

• Evaluate patients with MS for new-onset debilitating neurological symptoms to avoid unnecessary testing and admissions 3
• Consider the clinical presentation, including long tract signs, optic neuritis, or brainstem syndromes, as well as cortical syndromes or multifocal presentations 3, 4
• Use diagnostic testing, such as imaging and lumbar puncture for cerebrospinal fluid analysis, to confirm the diagnosis of an MS flare-up 3
• Develop a triaging system for patients with MS based on symptom stratification to avoid unnecessary MRIs and neurology admissions 5

Common Symptoms of MS Flare-Up

Common symptoms of an MS flare-up include:

• Discrete episodes of numbness, tingling, weakness, vision loss, gait impairment, incoordination, imbalance, and bladder dysfunction 4
• New neurologic symptoms, such as fever and vertigo, which can be confounding factors in diagnosis 6
• Worsening preexisting symptoms, which can be difficult to distinguish from new relapses 5

Importance of Accurate Diagnosis

Accurate diagnosis of an MS flare-up is crucial to avoid unnecessary treatments and relieve patients' symptoms 6

• Delayed diagnosis can lead to increased morbidity and long-term disability 3, 7
• Prompt diagnosis and early initiation of disease-modifying treatment can improve long-term outcomes in MS patients 7