What is the best course of treatment for a patient with a history of Multiple Sclerosis (MS) who is experiencing difficulty opening their eyes and recognizing people, suggesting a possible relapse?

Treatment of MS Relapse with Ocular and Cognitive Symptoms

This patient is experiencing an MS relapse and should be treated with high-dose intravenous corticosteroids (typically methylprednisolone 1000 mg daily for 3-5 days), which is the standard acute relapse management for multiple sclerosis. 1, 2

Confirming a True Relapse

Before initiating treatment, you must distinguish this from pseudo-relapses or symptom fluctuation:

• True relapses are new or worsened neurologic symptoms lasting at least 24 hours in the absence of fever or infection 3, 1
• The combination of difficulty opening eyes (suggesting optic nerve or brainstem involvement) and facial recognition problems (prosopagnosia, suggesting occipital/temporal cortical involvement) represents new neurological dysfunction consistent with active demyelination 4
• Rule out infection, fever, or metabolic disturbances that could cause pseudo-relapses 1, 5

Acute Relapse Treatment Protocol

Corticosteroid therapy is the cornerstone of acute relapse management:

• High-dose intravenous methylprednisolone (1000 mg daily for 3-5 days) is the standard approach 1, 2
• This reduces inflammation and accelerates recovery from acute relapses 2
• Treatment should be initiated promptly once true relapse is confirmed 1

Diagnostic Workup During Relapse

Obtain brain MRI with gadolinium enhancement to confirm active inflammatory lesions:

• Gadolinium-enhancing lesions indicate blood-brain barrier breakdown and active inflammation 3
• T2-weighted sequences are most sensitive for demonstrating MS lesions 3
• MRI should be performed at least 5 minutes post-gadolinium injection, as most lesions show maximum enhancement 5-30 minutes after injection 3
• In relapsing-remitting MS, approximately 80% of new lesions show gadolinium enhancement 3, 6

Disease-Modifying Therapy Considerations

After treating the acute relapse, reassess the patient's disease-modifying therapy (DMT):

• If the patient is not on DMT, initiate treatment as multiple FDA-approved options exist for relapsing forms of MS, including glatiramer acetate 7, interferon beta-1a 8, and more efficacious agents like ocrelizumab 9
• If already on DMT, this breakthrough relapse suggests inadequate disease control and warrants escalation to higher-efficacy therapy 2, 10
• Current DMTs reduce annualized relapse rates by 29-68% compared to placebo 2

Clinical Monitoring

Follow-up assessment should include:

• Clinical evaluation for relapse recovery and residual deficits 1, 5
• Repeat MRI within 3-12 months to assess treatment response and new lesion development 9
• Expanded Disability Status Scale (EDSS) scoring to document disability progression 3

Common Pitfalls to Avoid

• Do not delay corticosteroid treatment while waiting for MRI confirmation if clinical presentation strongly suggests relapse 1
• Do not mistake pseudo-relapses (symptom worsening from fever, infection, heat) for true relapses requiring corticosteroids 1, 5
• Do not continue ineffective DMT after breakthrough relapses—escalate therapy 2, 10
• Do not rely solely on MRI as it may not be rapidly accessible and could miss lesions 5