29-Year-Old Woman with Recurrent Neurological Episodes and White Matter Lesions

Case at a Glance

A 29-year-old woman presented with recurrent episodes of neurological symptoms including left-sided weakness, sensory changes, visual disturbances, and speech/mobility impairment. Initial workup revealed white matter lesions on MRI and optic neuritis diagnosed by ophthalmology. Despite clear neurological findings, she received conflicting diagnoses from neurology including complex migraines and functional neurological disorder.

Patient's Story

The patient first presented to the emergency department in May 2024 with acute onset of left-sided weakness and sensory changes that progressively worsened over one week. She also developed right eye symptoms and was subsequently diagnosed with optic neuritis by hospital ophthalmology. A second, more severe episode occurred in March 2025, during which she experienced loss of speech and inability to walk, with symptoms lasting 2-4 weeks before gradually resolving. She has no prior history of headaches or migraines. Genetic testing revealed she is a carrier of the HLA-DRB1*1501 allele associated with increased MS risk.

Initial Assessment

Initial MRI in July 2024 showed two 5mm T2/FLAIR hyperintensities - one periventricular adjacent to the right frontal horn and one subcortical in the left temporal lobe. Optic nerves appeared symmetric with no enhancement at that time. Complete spine imaging showed no cord abnormalities. Ophthalmology confirmed optic neuritis diagnosis.

The Diagnostic Journey

The patient was referred to the MS clinic but saw a resident physician rather than the department head. Despite MRI findings and ophthalmology diagnosis, she was initially diagnosed with complex migraines and prescribed migraine medications, which she declined due to concerns about interactions with psychiatric medications. After the second episode, the diagnosis was changed to functional neurological disorder (FND) with minimal support or resources provided.

Final Diagnosis

Follow-up MRI in July 2025 demonstrated stable appearance of 4-5 bifrontal subcortical and periventricular FLAIR hyperintense lesions with no new lesions identified. Notably, the study revealed 'focal abnormal signal and volume loss within the intraorbital right optic nerve in keeping with prior optic neuritis,' confirming the ophthalmology diagnosis that had been previously questioned.

Treatment Plan

Patient was prescribed migraine prophylaxis medications initially, which she did not take due to concerns about drug interactions and disagreement with the diagnosis. After the FND diagnosis, she was provided only with educational website resources and no specific treatment plan.

Outcome and Follow-up

The patient remains symptomatic with recurring neurological episodes. MRI findings show stable white matter lesions and confirmed evidence of prior optic neuritis. She is seeking a second opinion due to feeling dismissed and inadequately evaluated, particularly given the objective findings on imaging and the clinical pattern of her presentations.