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Answer 3
  1. Antibiotics for treatment of a UTI. The patient’s history indicates a UTI, possibly pyelonephritis. The T2-weighted MRI of the thoracic spine shows a spinal cord lesion, and the lack of contrast enhancement on the T1-weighted postcontrast MRI indicates that the lesion is not active (Figure). Segmental thinning of the cord is also demonstrated, indicating the chronic nature of the lesion. Overall, this is consistent with the history of prior transverse myelitis. Recrudescence is a well-recognized phenomenon in patients with chronic brain lesions and especially in MS. The classic picture of neurologic recrudescence is mild-to-moderate worsening of prior or chronic symptoms in the context of a febrile illness. UTIs are the most common infections in patients with MS. One study found that 35% of MS patients admitted with exacerbations had an acute bacterial infection, and 86% of these were UTIs.3 Most MS patients with UTI return to baseline function with treatment of the underlying infection with antibiotics. Concurrent administration of corticosteroids can impair treatment of infections; however, a course of corticosteroids could be considered if symptoms persisted after an adequate course of antibiotic treatment. Adjusting medications intended to reduce the rate of relapse (glatiramer and interferon beta-1a) would not be indicated in this case.

    3. Hillman LJ, Burns SP, Kraft GH. Neurological worsening due to infection from renal stones in a multiple sclerosis patient. Mult Scler 2000;6:403-6.

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