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Introduction A 29-year-old female presented with subacute onset ataxia, nystagmus, and vomiting with right-sided altered taste and left facial paraesthesia.An initial MRI head and spine with contrast showed inflammatory lesions highly suggestive of demyelination and in keeping with a diagnosis of multiple sclerosis (MS). She was treated initially with oral prednisolone but deteriorated with persistent vomiting, a reduced level of consciousness, weakness in the lower limbs, ophthalmoplegia, and dysarthria.A repeat MRI scan showed multiple ring-like demyelinating lesions. CSF examination revealed matched oligoclonal bands. Serum MOG and AQP-4 antibodies were negative.She received intravenous methylprednisolone and plasma exchange in intensive care and was commenced on natalizumab but deteriorated with a further reduction in level of consciousness and left-sided hemiplegia. She received a second cycle of plasma exchange, followed by cyclophosphamide and rituximab following a local vasculitis induction protocol.She has since significantly improved both clinically and radiologically and been discharged.Conclusion This case highlights the complexities of managing patients with a fulminant presentation MS, who can be unresponsive to first line treatments and who may require significant immunosuppression including with cyclophosphamide to achieve clinical improvement. There is currently a limited evidence base for treating such patients.Nicholas.heng@nhs.net