Multiple Sclerosis: A patient's experience in the ED

Karen Greenberg, DO, Andy Little, DO, and Leighann Marutz, MD

on Spotify

The summary below is from an episode of ERcast: Clinical Perspectives

Multiple sclerosis patients often come to the ED for infection, pain, falls, bladder dysfunction, or medication effects rather than a true inflammatory relapse. A real relapse means new or worsening neurologic deficits lasting more than 24 hours without fever or infection, and high-dose corticosteroids remain first-line therapy.

MS Relapse Versus Pseudoexacerbation

True relapse definition: A true MS relapse is a new neurologic deficit or worsening of prior symptoms lasting more than 24 hours in the absence of fever or infection, a distinction that drives everything else in the workup.
Infection-first diagnostic frame: UTIs and other infections commonly trigger pseudoexacerbations, so CBC, chemistries, urinalysis, and targeted cultures come before labeling worsening symptoms as new demyelinating disease.
Non-inflammatory ED presentations: Most ED visits in MS are not acute relapses but pain, fatigue, falls, urinary complaints, medication effects, or mental health symptoms. That early split is worth hearing in the episode.
Focused neurologic comparison: The bedside exam hinges on documenting what is truly new versus baseline deficits, because patients often carry chronic weakness, sensory loss, gait instability, or visual symptoms.
MRI as confirmatory test: MRI brain or spine with gadolinium is the gold standard for showing new lesions, but it is often unnecessary from the ED unless neurology needs it for diagnostic uncertainty or disposition.

ED Management And Disposition

Steroid first-line therapy: High-dose IV methylprednisolone is the cornerstone of acute relapse treatment, with oral high-dose steroids sometimes used when neurology agrees and outpatient logistics are reliable.
Symptom-directed treatment priorities: Spasticity, neuropathic pain, fatigue, bladder dysfunction, and dysphagia often need more ED attention than immunotherapy, with sedation and aspiration risk shaping early choices.
Polypharmacy and immunosuppression: Many MS patients take disease-modifying and symptomatic drugs simultaneously, raising the stakes for drug interactions, steroid adverse effects, and opportunistic infection.
Neurology consultation threshold: Neurology is almost always involved for true relapses, management changes, refractory symptoms, or diagnostic uncertainty. We get into the practical consult threshold in the chapter.
Admission red flag features: New inability to ambulate, dysphagia, vision loss, need for PLEX or IVIG, or major diagnostic uncertainty should push disposition toward admission rather than reflexive discharge.

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References:

Rodríguez de Antonio LA, García Castañón I, Aguilar-Amat Prior MJ, Puertas I, González Suárez I, Oreja Guevara C. Non-inflammatory causes of emergency consultation in patients with multiple sclerosis. Neurologia (Engl Ed). 2021;36(6):403-411. PMID: 34238522
Makkawi S, Maglan A, Khojah O, et al. Patterns of multiple sclerosis presentation to the emergency department. Front Neurol. 2024;15:1395822. Published 2024 Apr 26. PMID: 38737348
Ruiz-Algueró M, Zhu F, Chertcoff A, Zhao Y, Marrie RA, Tremlett H. Health Care Use Before Multiple Sclerosis Symptom Onset. JAMA Netw Open. 2025;8(8):e2524635. Published 2025 Aug 1. PMID: 40748636

Faculty

Andy Little, DO
Dr. Andy Little is an emergency medicine physician and educator. He earned his medical degree from the Ohio University Heritage College of Osteopathic Medicine and completed his emergency medicine residency at OhioHealth Doctors Hospital Emergency Medicine Residency, where he served as Chief Resident. He has received multiple national awards, including recognition from the American Osteopathic Association, American College of Osteopathic Emergency Physicians, and Emergency Medicine Residents' Association.
Karen Greenberg, DO
Leighann Marutz, MD