Multiple Sclerosis (MS)

Last updated 20.09.12

 

Definition

-  Incurable AID of the CNS with variable presentations

 

Features

-  Potentially debilitating

- Most common chronic disabling disease of CNS in young adults

- Pregnancy: typically disease activity reduces but higher risk of relapse post partum

- Prognosis

-  Improved

- Optic neuritis or isolated sensory symptoms as CIS

- Initial relapsing remitting course

- Long interval to second relapse

- No disability after 5yrs

- Normal initial MRI

- Female

- Younger age of onset

- Complete recovery from first episode

- Poor

- Efferent systems or multifocal CIS

- High relapse rare in first 2-5yrs

- Substantial disability after 5yrs

- Abnormal initial MRI

 

Dx

-  Objective clinical evidence of 2+ lesions disseminated in space & time without better explanation for symptoms

 

Types

Relapsing Remitting 85%

-  Attacks every 1-2yrs

- Acute episodes days/weeks/months with complete or parital recovery

- Midl residual symptoms in 40%

- Secondary Relapsing Remitting

-  Develops from Relapsing Remitting type

- Less frequent relapses

- 60% patients with Relapsing Remitting progress to this type within 15yrs

- Primary Progressive 10%

-  Gradual onset of symptoms without recovery

- Typically progressive spastic paraparesis, cerebellar or hemiplegic syndrome

- Relapsing Progressive 5%

-  Disability builds up between relapses

 

Cause

-  Autoimmune destruction of myelin sheaths (plaques)

- Idiopathic

- ?viral trigger

 

Risk Factors

-  Age: 20-50yrs

- Female 70%

- Caucasian

- Temperate zones

- Relatives with MS

- AID: thyyroid, DM1, IBD

 

DDx

- Neruomyelitis Optica

- Amyotrophic Lateral Sclerosis

-  ADEM (Acute Disseminated Encephalomyelitis)

-  Monophasic disease of prepubertal children

-  Occurs after prodromal febile illness

-  Encephalopathy

 

Associated S/S

-  Varied & unpredictable

- Clinically Isolated Syndrome (CIS) or First Demyelinating Event

-  21% patients first event is optic neuritis

- 46% long tract (motor or sensory)

- 10% brainstem syndrome

- 23% multifocal

- Motor

-  Spasms

- Weakness

- Tremor

- Balance: gait ataxia

- Co-ordination: limb ataxia

- Torsional gaze evoked nystagmus

- Erectile dysfunction

- Heat sensitivity: worsened/precipitated by heat

- Continence

-  Urinary incontinence

- Constipation

- Sensory

-  Neuralgia

- L'Hermittes phenomenon: short electric shock like sensation on neck movement

- Paresthesia

- Vertigo

- Visual changes

- Optic neuritis: central vision loss/blurred vision with pain on eye movement & color desaturation

- Fatigue

- Neuropsych

-  Memory loss

- Depression

- Cognition

 

Ix

- MRI: white matter lesions

- LP: oligoclonal bands, raised IgG index

- Evoked potential studies: delayed evoked response with preserved maveform

 

Mx

-  Dependant on type

- Referral to Neurologst

- Immunotherapy

-  Interferon B-1a (Avonex, Rebif)

- Interferon B-1b (Betaferon)

- Glatiramer (Copaxone)

- Natalizumab (Tysabri)

- Fingolimod (Gilenya)

- Mitoxantrone (Onkotrone)

- Cyclophosphamide (Endoxan, Cycloblastin)

- Corticosteroids

- IV Methylprednisolone 1g/day for 3 days if relapses impact on QOL

- Hastens recovery but not the likelihood of recovery, frequency of attacks or disability from attacks

- Physiotherapy

- Mx of other S/S

- Spasticity: Baclofen 10-25mg Nocte OR 5-25mg TDS

- Fatigue: Amantadine 50-100mg BD

- Intention tremor: Clonazepam 0.5mg/day increased up to 6mg/day

- Urinary urgency: Oxybutynin 2.5-5mg BD/TDS

- +/- Continence aids

- +/- Counselling

 

 

 

References

 

  MS Society of Australia

MayoClinic: MS

Better Health Channel: MS

AFP: MS