Multiple Sclerosis

Epidemiology

  • Geography: more common in temperate climates
  • Age of Onset: 15-60 y/o
  • Sex
  • Familial Cases

Diagnosis

Complete Blood Count (CBC) (see Complete Blood Count, [[Complete Blood Count]])

  • xxx

Brain Magnetic Resonance Imaging (MRI) (see Magnetic Resonance Imaging, [[Magnetic Resonance Imaging]])

  • Demyelination/Plaques

Spine Magnetic Resonance Imaging (MRI) (see Magnetic Resonance Imaging, [[Magnetic Resonance Imaging]])

  • Demyelination/Plaques

Lumbar Puncture (see Lumbar Puncture, [[Lumbar Puncture]])

  • Total Protein: elevated
  • Cell Count
    • Pleocytosis: 25% of cases have WBC >5 per µL (with mononuclear predominance)
      • WBC >50 per µL is unusual, but may occur at onset of disease
      • WBC >75 per µL makes MS diagnosis unlikely
  • Oligoclonal IgG Banding: present in XXX

Electromyogram (EMG)/Nerve Conduction Velocity (NCV) (see xxxxx, [[xxxx]])

  • xxx

Clinical Manifestations

General Comments

Clinical Features Which are Suggestive of Multiple Sclerosis

  • Chronology: relapses and/or remissions
  • Onset: between age 15-50 y/o
  • Clinical Features: polysymptomatic onset occurs in 14% of cases
    • Fatigue (see Fatigue, [[Fatigue]])
    • Heat Sensitivity (Uhthoff Phenomenon)
    • Internuclear Ophthalmoplegia (see Internuclear Ophthalmoplegia, [[Internuclear Ophthalmoplegia]])
    • Lhermitte Sign (see Lhermitte Sign, [[Lhermitte Sign]]): present in 2% of cases
      • Electric shock-like sensations that run down the back and/or limbs upon neck flexion
    • Optic Neuritis (see Optic Neuritis, [[Optic Neuritis]])

Clinical Features Which are Atypical of Multiple Sclerosis

  • Chronology: gradual progression
  • Onset: before 10 y/o and after 50 y/o
  • Clinical Features
    • Cortical Deficits
      • Alexia (see Alexia, [[Alexia]])
      • Aphasia (see Aphasia, [[Aphasia]])
      • Apraxia (see Apraxia, [[Apraxia]])
      • Neglect
    • Deficits Developing Within Minutes
    • Early-Onset Dementia (see Dementia, [[Dementia]])
    • Rigidity/Sustained Dystonia (see Dystonia, [[Dystonia]])
    • Seizures (see Seizures, [[Seizures]])

Neurologic Manifestations

Brainstem Symptoms

  • Internuclear Ophthalmoplegia (see Internuclear Ophthalmoplegia, [[Internuclear Ophthalmoplegia]])
  • Trigeminal Neuralgia (see Trigeminal Neuralgia, [[Trigeminal Neuralgia]]): facial sensory symptoms are present in 3% of cases
    • Trigeminal neuralgia in a young adult may be an early sign of MS

Cortical Symptoms

  • General Comments: much less common in MS
  • Aphasia (see Aphasia, [[Aphasia]])
  • Visual Field Disturbances

Long Tract Symptoms

  • Brown-Sequard Syndrome (see Brown-Sequard Syndrome, [[Brown-Sequard Syndrome]])
    • xxx
  • Numbness (see xxxx, [[xxxx]])
    • Sensory Symptoms in Extremities: present in 31% of cases (sensory symptoms are the most common initial feature of MS)
  • Parasthesias (see Parasthesias, [[Parasthesias]])
    • Sensory Symptoms in Extremities: present in 31% of MS cases sensory symptoms are the most common initial feature of MS)
  • Weakness (see xxxx, [[xxxx]])
    • Acute Motor Symptoms: present in 4% of cases
    • Subacute Motor Symptoms: present in 9% of cases

Spinal Cord Symptoms

  • Transverse Myelitis (see Transverse Myelitis, [[Transverse Myelitis]]): present in 1% of cases

Ophthalmologic Manifestations

Diplopia (see Diplopia, [[Diplopia]])

  • Epidemiology: present in 7% of MS cases

Optic Neuritis (see Optic Neuritis, [[Optic Neuritis]])

  • Epidemiology
  • Clinical
    • Acute/Subacute Unilateral Eye Pain (see Eye Pain, [[Eye Pain]]): accentuated by eye movements
    • Afferent Pupillary Defect (Marcus-Gunn Pupil) (see Marcus-Gunn Pupil, [[Marcus-Gunn Pupil]])
    • Desaturation of Bright Colors (Particularly Red): often reported following episode of optic neuritis
    • Visual Loss (Scotoma): present in 16% of MS cases
  • Prognosis: 90% of cases regain normal version over 2-6 mo after an acute optic neuritis episode

Pulmonary Manifestations

Respiratory Failure (see Respiratory Failure, [[Respiratory Failure]])

  • xxx

Clinical courses:
-Acute MS (Malignant Monophasic MS/ Marburg Disease): rare variant with fulminant disease, which may be rapidly fatal
-Relapsing MS:

-Chronic, progressive MS:
-Inactive MS:

Symptoms:
-Weakness (35%):
-Sensory loss (37%):
-Parasthesias (24%):
-Visual symptoms due to optic neuritis (36%):
-Diplopia (15%):
-Ataxia (11%):
-Vertigo (6%):
-Lhermitte sign (3%):

  • Acute/Chronic Hypoventilation

Treatment

Supportive Care

Mechanical Ventilation

  • Rocking Bed
  • Positive Pressure Ventilation

Immunotherapies

Glatiramer Acetate (Copaxone) (see Glatiramer Acetate, [[Glatiramer Acetate]])

  • xxx

Interferon Beta-1a (Avonex, CinnoVex, Rebif) (see Interferon Beta-1a, [[Interferon Beta-1a]])

  • xxx

Interferon Beta-1b (Betaseron, Betaferon) (se Interferon Beta-1b, [[Interferon Beta-1b]])

  • xxxx

Dimethyl Fumarate (Tecfidera) (see Dimethyl Fumarate, [[Dimethyl Fumarate]])

  • xxx

Fingolimod (Gilenya) (see Fingolimod, [[Fingolimod]])

  • xxx

Mitoxantrone (see Mitoxantrone, [[Mitoxantrone]])

  • xxx

Natalizumab (Tysabri) (see Natalizumab, [[Natalizumab]])

  • xxxx

Teriflunomide (Aubagio) (see Teriflunomide, [[Teriflunomide]])

  • xxx

Corticosteroids (see Corticosteroids, [[Corticosteroids]])

Indications

  • xxx

Adverse Effects

  • Arrhythmias: smokers or patients with autonomic disturbances (such as sphincter and bowel problems) have increased risk of developing arrhythmias while receiving high dose corticosteroids for multiple sclerosis

Plasmapheresis (see Plasmapheresis, [[Plasmapheresis]]))

  • May Be Useful for Acute Multiple Sclerosis

Phrenic Nerve Pacing

  • xxxx

References

  • Incidence of various cardiac arrhythmias and conduction disturbances due to high dose intravenous methylprednisolone in patients with multiple sclerosis. J Neurol Sci. 2011 Oct 15;309(1-2):75-8. doi: 10.1016/j.jns.2011.07.018. Epub 2011 Aug 9 [MEDLINE]