Multiple Sclerosis

Page 1

MULTIPLE SCLEROSIS -It is an immune-mediated inflammatory disease that attacks myelinated axons in the central nervous system, destroying the myelin and the axon in variable degrees and producing significant physical disability within 20-25 years in more than 30% of patients.

Etiology: Multifactorial. genetic, environmental trigger, focal areas of demyelination.

Symptoms: weakness, numbness, tingling or unsteadiness of a limb. urinary urgency or retention. blurry vision. double vision.

Cerebellar symptoms: Charcot triad of dysarthria, ataxia, and tremor

Optic neuritis

Trigeminal neuralgia: Bilateral facial weakness or trigeminal neuralgia

Facial myokymia (irregular twitching of the facial muscles): May also be a presenting symptom

Eye symptoms: Including diplopia on lateral gaze (33% of patients)

Heat intolerance

Constitutional symptoms: Especially fatigue (70% of cases) and dizziness

Pain: Occurs in 30-50% of patients at some point in their illness

Subjective cognitive difficulties: With regard to attention span, concentration, memory, and judgment

Depression: A common symptom

Euphoria: Less common than depression

Bipolar disorder or frank dementia: May be a late finding but is sometimes found at initial diagnosis

Symptoms associated with partial acute transverse myelitis

Relapsing remitting disease

- relapse of active disease with incomplete recovery during the periods of remission; the progression of disease worsen and more aggressive causing a consistent worsening of function occurs. = SECONDARY PROGRESSIVE DISEASE

- disease that is progressive from the onset of the disease with early onset of disability = PRIMARY PROGRESSIVE DISEASE.

TO diagnose a patient:

normally patient less than 55 years, history of multiple neurologic complaints, that is multiple neurologic deficits separated by TIME AND SPACE.

Triggers of the disease; trauma and infection. Pregnancy - especially 2 to 3 months following birth.

Diagnosis:

Clinical, Radiology and Lab

MRI: most accurate test to diagnose MS. Present increase T2 density and decreased T1 intensity represent the increased water content of demyelinated plaques.

Active MS lesion: enhancement of lesions with gadolinium.

Evoked response potentials: detect slow or abnormal conduction in response to visual, auditory or somatosensory stimuli. (NOT SPECIFIC TEST)

CSF: reveal mild pleocytosis and protein mild elevated. Any protein level above 100 is unusual, normally indicate Dx against MS.

elevated IgG index (oligoclonal bands) found in 70 to 90% of patients with MS. (non specific)

Treatment

relapsing-remitting disease: IFN-B1a, IFN-B1b and glatiramer acetate. These are to reduce the number of clinical exacerbations and number of MRI lesions. Also can delay the onset of disability.

Secondary Progressive Dx; IFN-B1b and mitoxantrone are used and have shown reduced number of exacerbations, MRI activity and delay onset of disability.

mitoxantrone: cardiotoxic ! before usage, need to check patient's ejection fraction.

Management

Treatment of MS has 2 aspects: immunomodulatory therapy (IMT) for the underlying immune disorder and therapies to relieve or modify symptoms.

Treatment of acute relapses is as follows:

Methylprednisolone (Solu-Medrol) can hasten recovery from an acute exacerbation of MS

Plasma exchange (plasmapheresis) can be used short term for severe attacks if steroids are contraindicated or ineffective [8]

Dexamethasone is commonly used for acute transverse myelitis and acute disseminated encephalitis

Symptoms treatment:

spasticity: baclofen

noctural spasticity: diazepam and tizanidine

Pain: carbamazepine, gabapenti, phenytoin.

Bladder hyperactivity: oxybutynin

Bladder retention: bethanechol

fatigue: amantadine or fluoxetine.

Erectile dysfunction: sildenafil acetate.

The FDA has approved alemtuzumab for relapsing forms of multiple sclerosis. Because of the risk for severe autoimmune adverse effects, it is reserved for use in patients who have an inadequate response to two or more other drugs for MS.