DRKUPE’S NOTE ON

drkupe

MULTIPLESCLEROSIS

Irfan Ziad MD UCD

is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms

MULTIPLESCLEROSIS

>Predominant age: 20-40

MULTIPLE SCLEROSIS AFFECT:0.1%Worldwide incidence

Higher incidence in Northern European descent and in temperate climate, but the latitude gradient is decreasing

The ratio is increasing

now

people in US have MS

400, 000 1–3% risk of MS among 1st-degree relatives

worse prognosis

Highly variable and unpredictable

Blood-brain barrier breakdown

The BBB prevent entrance of T cells into the nervous system. The blood–brain barrier is normally not permeable to these types of cells, unless triggered by infection or a virus, which decreases the integrity of the tight junctions. When the blood–brain barrier regains its integrity, usually after infection or virus has cleared, the T cells are trapped inside the brain.

Autoimmunology The immune system attacks the nervous system, forming plaques or lesions.Commonly involves white matter.Destroys oligodendrocytes- causing demyelinationRemyelination occurs in early phase but not completely.Repeated attacks lead to fewer remyelination.

Inflammation T-cells attacks on myelin triggers inflammatory processes, stimulating other immune cells and soluble factors like cytokines and antibodies. Leaks form in the BBB cause swelling, activation of macrophages, and more activation of cytokines and other destructive proteins

Pathophysiology

PRMS Progressive Relapsing MS

SPMS Secondary Progressive MS

PPMS Primary Progressive MS

RRMS Relapsing/ Remitting MS

CLASSIFICATION OF MULTIPLE SCLEROSIS

Gradual progression of the disease from its onset with no relapses or remissions

Unpredictable attacks which may or may not leave permanent deficits followed by periods of remission

Initial RRMS that suddenly begins to decline without periods of remission and relapses.

Steady decline since onset with super-imposed attacks.

The most common initial symptoms •changes in sensation in the arms, legs or face (33%)•Optic neuritis (20%)•weakness (13%)•double vision- internuclear opthalmoplegia (7%)•unsteadiness when walking (5%)•and balance problems (3%)

Lhermitte's sign  (25-40%) is an electrical sensation that runs down the back and into the limbs and is produced by bending the neck forwards. The sign

suggests a lesion of the dorsal columns of the cervical cord or of the caudal medulla.

Uhthoff's phenomenon is the worsening of neurologic symptoms in multiple sclerosis and other neurological,

demyelinating conditions when the body gets overheated from hot weather, exercise, fever, or saunas and hot

tubs.

EDSS is a method of quantifying disability in multiple sclerosis based on eight Functional Systems (FS)

Expanded Disability Status Scale (EDSS)

•Pyramidal (ability to walk)•Cerebellar (coordination)•Brain stem (speech and swallowing)•Sensory (touch and pain)•Bowel and bladder functions•Visual•Mental•Other (any other neurological findings)

Normal Neurological Exam

0.0

Death due to MS10.0

1.0

4.5

5.0

9.5

Fully ambulatory

Ambulation impairment

A graph showing the average time a person spends in each EDSS level.

Diagnosis is based on McDonald’s Criteria (Revised 2010)

CSF oligoclonal bands, abnormal colloidal gold curve, elevated γ-globulin IgG, mild mononuclear pleocytosis (<40 cells/mL), myelin debris, normal or slightly elevated protein. (Myelin basic Protein)

Blood test •B-12 and folate levels or antinuclear antibody (ANA) titers. •Antiphospholipid antibody syndrome must be undertaken in patients with evidence of blood dyscrasia and in women with unexplained miscarriages or history of deep venous thrombosis.•elevated erythrocyte sedimentation rate (ESR) and positive titers of rheumatoid factor (RF) should help identify the presence of a vasculitic disorder that may be mimicking MS.

MRI MRI of the head and spine (more sensitive than CT): May show many plaques. MRI reveals multiple lesions with high T2 signal intensity and one large white matter lesion. These demyelinating lesions may sometimes mimic brain tumors because of the associated edema and inflammation.

• INVESTIGATION

"Dawson's Fingers” is the name for the multiple sclerosis lesions around the

ventricle-based brain veins of Multiple

Sclerosis patients seen on MRI

MANAGEMENT

Steroids: methylprednisolone (MP) 500–1,000 mg/d IV for 5 days followed by tapered oral prednisone or MP 1 g/d IV for 3 days ± oral taper

ACUTE

ATTACKACUTE

ATTACK

As of 2011, six treatments have been approved by FDA1.Interferon beta-1a (Avonex, CinnoVex,ReciGen and Rebif) 2.Interferon beta-1b (Betaseron )3.Glatiramer acetate (Copaxone), a non-steroidalimmunomodulator. 4.Mitoxantrone, is an immunosuppressant 5.Natalizumab (Tysabri)6.Fingolimod (Gilenya)

The interferons (side effects include flulike symptoms, injection-site reactions, mild liver dysfunction) and glatiramer acetate are delivered by frequent injections, varying from once-per-day for glatiramer acetate to once-per-week (but intra-muscular) for Avonex. Natalizumab and mitoxantrone are given by IV infusion at monthly intervals.

DISEASE MODIFYING TREATMENT

DISEASE MODIFYING TREATMENT

Spasticity Baclofen 5 mg PO 1–3 t.i.d. and increase as needed Diazepam 2–5 mg PO at bedtime

Pain NSAIDs Gabapentin effective vs. MS pain syndromes at 300 mg/d PO, may increase to 1,800 mg/d within 1 week, max dose 3,600 mg/d

Bladder dysfunction

Propantheline 7.5 mg PO q3–4h to start, increase to 15 mg t.i.d. to q.i.d. plus 15–30 mg at bedtime Oxybutynin chloride 5 mg PO t.i.d.–q.i.d. Prophylactic antibiotics for urinary infectionsSelf-catheterizations  for inadequate bladder emptying

Constipation: Stool softeners, bulk-producing agents, laxative suppositories

Incoordination or tremors:

Incoordination or tremors:

Depression and emotional lability

Antidepressant agents such as SSRIs. Psychotherapy and support

Paranoia or mania

Haloperidol lithium or atypical antipsychotic

Hemifacial and dysesthesias

Carbamazepine 100–200 mg PO once or twice a day to start; increase to total daily dosage of 600–1,600 mg t.i.d.–q.i.d. Must monitor serum levels

MANAGEMENT MANAGE MS SYMPTOMS

MANAGE MS SYMPTOMS