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Ms. VA - Coggle Diagram

- - - - Now lives in Massachusetts
- - - - Anti-CD20 antibodies
        
        CD0 found on B-cells -> antibody-dependent cytotoxicity and complement dependent cytotoxicity
        
        Higher efficacy compared to fumaric acid derivatives
        
        Prevented relapses and disability progression better than dimethyl fumarate
      - Ocrelizumab
        
        Approved for primary progressive MS and relapsing
        
        Approved in 2017
    - - MOA: unknown, may activate Nrf2 pathway and modify cysteine residues on GAPDH, preventing aerobic glycolysis in lymphocytes
      - Dimethyl Fumarate
        
        Approved in 2013
      - Approved for relapsing MS
  - - - Removes CSF signal to highlight static fluid
    - - 7 unpaired electrons in 4f shell -> strongly paramagnetic -> strong MRI signal
      - Chelated into a large molecule -> if it crosses into the CNS it means there is some sort of leakiness (damage) to the BBB, like in MS
        
        Readily dissolves in water and is quickly excreted by the kidneys
  - - - Presents in young women aged 20-40 y/o
      - Relapse-Remitting MS lasts 10 years before progressing to secondary progressive MS
    - - HLA-DRB1 gene
      - IL7R gene
    - - Sensory Disturbances in limbs
        
        numbness
        
        pain
        
        itching
      - Decreased Motor Control
        
        tremors
        
        Hyperreflexia
        
        urinary incontinence
        
        difficulty walking
      - Vision changes
        
        Double/ blurred vision
        
        partial/ complete vision loss
    - - EBV
      - low levels vitamin D
      - smoking
- - - - Feels like legs are going to fall under her
      - red color "looks off"
        
        Red card looks more orange than red in her left eye
      - Blurry Vision
      - Eye aches when looking side to side
      - Gait favors left leg, stiffness with stride
      - Hard to take care of her son
    - - Visit 2
        
        Tightness in lower extremities, same symptoms as before
        
        Physical Exam
        
        Left eye does not fully adduct, right eye nystagmus
        
        Internuclear Ophthalmoplegia
        
        Subtle pain in left eye with double vision
        
        Eyes dilate rather than constrict when going from right eye to left eye
        
        Marcus Gunn pupils
        
        4/5 weakness, hyperreflexia (Brisk)
        
        sensory deficits
        
        Labs ordered: labs, spinal tab, MRI
        
        Referred to physical therapy and social work
        
        Visit 3
        
        MRI with contrast
        
        T2 Flair: hyperintense lesions in the brain along the ventricles, left optic nerve, and within cervical spine (1-2 levels)
        Gadolinium enhancing lesions
        
        CSF
        
        Oligoclonal bands, elevated IgG, normal protein, glucose, cells
        
        Visit 4
        
        Worsening gait, left sided spasticity, left hand weakness, urinary urgency
        = Worsening neurologic damage
        
        Put on Oxybutynin (m3 antagonist)
        
        Urgent MRIs, physical therapy, occupational therapy
        
        2 new lesions
        
        Get approval for Ocrelizumab
        
        MOA: monoclonal antibody against CD20 (B-cell expressing surface protein)
        
        MS concerns
        
        3 days IV Steroids
        
        Then
        
        B-cell depletion therapy
        
        1 more item...
        
        FHx: MS
        
        Work accommodations
        
        will likely be fired
      - Dr. Sodder = Neurologist
- - - - Anti-CD20 therapies are first line in clinical medicine, but insurance companies want to see failure on cheaper treatments first
      - Dimethyl Fumarate does not need a prior authorization
      - Ocrelizumab requires a prior authorization (expensive, new medication)
        
        If they have primary progressive MS or have tried + failed Brimuvi (Another anti-CD20 agent) they can get approval
      - Most MS drugs need prior authorization for MA Medicaid