Overview of Multiple Sclerosis

Valerie Robinson, D.O.

What is it?

• Multiple sclerosis is an inflammatory demyelinating disease, likely auto-immune.

• Affects the CNS• Causes multifocal areas of demyelination• Most commonly affects women of childbearing

age who are of Northern European descent.• There is a multiple-gene component

• Siblings 3-5%, Twins 20-40%

Signs and Symptoms

• Relapses and Remissions• Optic neuritis• Internuclear opthomoplegia• Sensory irregularities• Pain• Vertigo• Muscle weakness, spasticity, paraparesis or

paraplegia• Bowel/bladder/sexual dysfunction

Signs and Symptoms• Fatigue• Depression• Cognitive dysfunction• Difficulty with coordination• McDonald’s criteria

– multiple lesions are separated in space and time

• Uhthoff’s phenomenon – worsening of symptoms when the body temp increases

• Lhermitte’s sign – feeling of electric shock running down back and limbs upon

neck flexion

Diagnosis

• Clinical judgment confirmed by the following:• MRI shows demyelinated plaques that meet

McDonald’s criteria• CSF analysis: increased IgG, oligoclonal bands• Abnormal evoked potentials (visual,

somatosensory, and brainstem auditory)• Onset between age 15 and 50• Before 16 is considered pediatric = 5%

Exacerbations/Relapses

Acute neurologic impairment causing loss of function or severe discomfort.• Pregnancy, particularly 2-3 months post-

partum• Stress• Random

Types of MS

• Relapsing-remitting (RRMS): clear relapses with full or partial recovery. No progression between relapses.

• Primary-progressive (PPMS): From onset, disease progresses with occasional plateaus and temporary minor improvements.

• Secondary-progressive (SPMS): Onset as RRMS then begins to progress. With or without relapses, minor improvements and plateaus.

• Progressive-relapsing (PRMS): From onset, disease progresses. It has occasional clear relapses with full or partial recovery. Progression continues between relapses.

Differential

• CVA/TIA• Malignancy• Spinal cord injury or compression• A-V malformations• Lupus• Sjogren’s• Cerebellitis• Infections: such as meningitis, human T-

lymphocytic virus type 1, HIV, syphilis

Treatment of Progressive

• Immunosuppression– Azathioprine– Cladribine– Dalfampridine– Glucocorticoids– Cyclophosphamide– Cyclosporine

• Stem sell transplant

– Glatiramer acetate– Interferon– Methotrexate– Mitoxantrone– Natalizumab– Rituximab

• Total lymphoid irradiation

Treatment of Relapsing

• #1 Glucocorticoids• Interferon• Glatiramer acetate• Natalizumab• Plasma exchange if poor response to steroids

• Methylprednisolone 1 gram IV QD x 3-7 days– Pediatric: 20-30 mg/kg QD x 5 days

• May follow with a prednisone taper for residual disability

References

• Up-to-Date– Diagnosis of multiple sclerosis in adults– Epidemiology and clinical features of multiple sclerosis in

adults– Treatment of progressive multiple sclerosis in adults– Treatment of acute exacerbations of multiple sclerosis in

adults– Treatment of relapsing-remitting multiple sclerosis in

adults– Treatment and prognosis of pediatric multiple sclerosis