A 37-year-old White man presents with progressive worsening of leg weakness, gait imbalance, and paresthesia. These difficulties worsen when he is fatigued. Two years ago, he noted numbness in his toes that gradually spread to just above the knees. This has progressively worsened since the initial episode. More recently, he noted onset of urinary urgency and frequency, but no incontinence. Mental status and cranial nerves are intact. Sensation to light touch is altered in both lower extremities. Pin prick is intact. Vibration sense is intact in the hands, markedly decreased at the ankles, and absent at the toes. Reflexes are brisk, with a few beats of clonus at the ankles and an upgoing toe on the right foot.
Additional physical findings include blood pressure of 120/82 mm Hg, heart rate of 70 bpm, height of 5 ft 7 in, and weight of 142 lb (BMI, 22.2). Laboratory tests include complete blood count, chemistries, A1c, and B12. All test results were normal.
On the basis of his symptoms and findings on physical examination, this patient has a progressive myelopathy. There are several potential etiologies, but multiple sclerosis (MS) is considered a likely possibility.
