Multiple sclerosis: Difference between revisions

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==Background==
==Background==
#CNS myelin destruction causes variable motor, sensory, visual and cerebellar dysfunction
*CNS myelin destruction causes variable motor, sensory, visual and cerebellar dysfunction<ref>Multiple sclerosis: a practical overview for clinicians. British Medical Bulletin, Volume 95, Issue 1, September 2010, Pages 79–104. https://doi.org/10.1093/bmb/ldq017</ref>
#Types
 
##Relapsing/remitting (most common)
===Types===
###Relapse (days-months) followed by remission
*'''Relapsing/remitting (most common)'''
##Secondary progressive  
**Relapse (days-months) followed by remission
###Relapses and partial recoveries occur, but disability doesn't fade away between cycles
*'''Secondary progressive'''
##Primary progressive
**Relapses and partial recoveries occur, but disability does not fade away between cycles
###Symptoms progress slowly and steadily without remission
*'''Primary progressive'''
##Progressive relapsing
**Symptoms progress slowly and steadily without remission
###Similar to primary progressive but with superimposed flares
*'''Progressive relapsing'''
**Similar to primary progressive but with superimposed flares


==Clinical Features==
==Clinical Features==
#Classic pt has multiple presentations for neuro symptoms of different areas of pathology  
*Classic patient has multiple presentations for neuro symptoms of different areas of pathology  
##Pt often has resolution of the earlier symptoms
**Patient often has resolution of the earlier symptoms
#Symptoms worsen w/ increases in body temperature (Uhthoff's phenomenon<ref>Flensner G, et al. "Sensitivity to heat in MS patients: a factor strongly influencing symptomology-an explorative survey". BMC Neurol. 2011. 11:27.</ref>)
*Symptoms worsen with increases in body temperature, classically after hot showers (Uhthoff's phenomenon<ref>Flensner G, et al. "Sensitivity to heat in MS patients: a factor strongly influencing symptomology-an explorative survey". BMC Neurol. 2011. 11:27.</ref>)
#Muscle/sensory signs:
*Muscle/sensory signs:
##Lower extremity weakness usually worse than upper extremity
**Lower extremity [[weakness]] usually worse than upper extremity
##Upper motor neuron signs:
**Upper motor neuron signs:
###Hyperreflexia
***Hyperreflexia
###Positive Babinski
***Positive Babinski
##Decrease in proprioception / pain/temp sensation
**[[numbness|Decrease]] in proprioception/pain/temperature sensation
##Lhermitte sign
**Lhermitte sign
###Electric shock sensation radiating down back into arms/egs from neck flexion
***Electric shock sensation radiating down back into arms/egs from neck flexion
#Optic neuritis
***If the discomfort is severe, carbamazepine or gabapentin may be beneficial for some patients.
##Initial sign in 30% of pts
*[[Optic neuritis]]
##Vision loss (usually unilateral) often preceded by retrobulbar pain
**Initial sign in 30% of patients
##Blurred vision
**[[Vision loss]] (usually unilateral) often preceded by retrobulbar pain
##Nystagus
**[[Blurred vision]]
##[[Diplopia]]
**Afferent pupillary defect is suggestive of optic neuritis
##Internuclear ophthalmoplegia
**[[Nystagmus]]
###Abnormal eye adduction bilaterally and horizontal nystagmus
**[[Diplopia]]
#Dysautonomia
*[[Internuclear ophthalmoplegia]]
##Urinary retention (increased risk of UTI/pyelo)
**Abnormal eye adduction bilaterally and horizontal nystagmus
##Constipation or incontinence
**Convergence (both eyes center medially) is preserved
##Sexual dysfunction (males)
*Dysautonomia
 
**[[Urinary retention]] (increased risk of [[UTI]]/[[pyelo]])
==Diagnosis==
**[[Constipation]] or incontinence
#MRI
**Sexual dysfunction (males)
##Multiple lesions in supratentorial white matter, paraventricular area, spinal cord
#CSF
##Elevated protein and gamma-globulin (increased oligoclonal bands)


==Differential Diagnosis==
==Differential Diagnosis==
{{Weakness DDX}}
{{Weakness DDX}}


==Work-Up==
==Evaluation==
#LP
[[File:MS_MRI_1.jpg|thumb|MRI brain with contrast of a patient in her mid-20s with new onset MS. Large lesion in left parietal area.]]
##IgG
[[File:MS_MRI_2.jpg|thumb|MRI brain with contrast of same patient with new onset MS with another lesion in the left cerebellum.]]
##Albumin
*[[LP|CSF]]
##Oligoclonal bands
**Elevated protein and gamma-globulin (increased oligoclonal bands)
##myelin basic protein
*[[brain MRI|MRI]]
##Cell count
**Multiple lesions in supratentorial white matter, paraventricular area, spinal cord
##Glucose
*[[brain MRI|MRI]] with GAD of brain (+/- spine) and orbits (if [[optic neuritis]] suspected)
##Protein
*CBC, Chemistry
##Gm stain
*[[Urinalysis]]
#CBC, Chemistry
#UA
# MRI w/ GAD of brain (+/- spine)


==Treatment==
==Management==
#Fever must be reduced to minimize weakness assoc w/ elevated temperature
*Fever must be reduced to minimize weakness associated with elevated temperature
#Abx for UTI/pyelo
===Infection Treatment===
#High-dose steroid therapy for relapses
*Antibiotics or surgical control of any infectious sources
===Steroids and Immunomodulators===
*High-dose [[Corticosteroids|steroid]] therapy for relapses in the form of oral or intravenous methylprednisolone (1000 mg)<ref>Le Page et al. Oral versus intravenous high-dose methylprednisolone for treatment of relapses in patients with multiple sclerosis (COPOUSEP): a randomised, controlled, double-blind, non-inferiority trial. Lancet. 2016 Jan 23;387(10016):340. https://core.ac.uk/download/pdf/52993687.pdf</ref>
*Suppression therapies
**IFN B, Glatiramer, Estriol (usually not in ED)


==Disposition==
==Disposition==
#Hospitalization indicated for:
*Hospitalization indicated for:
##Any disease exacerbation a/w significant morbidity
**Any disease exacerbation associated with significant morbidity
##IV abx or steroid therapy required
**IV antibiotics or steroid therapy required
##Depression and significant risk of suicide
**Depression and significant risk of suicide


==See Also==
==See Also==
[[Optic Neuritis]]
*[[Optic Neuritis]]
 
==Source==
Tintinalli


==References==
<references/>
<references/>


[[Category:Neuro]]
[[Category:Neurology]]

Latest revision as of 21:01, 16 November 2022

Background

  • CNS myelin destruction causes variable motor, sensory, visual and cerebellar dysfunction[1]

Types

  • Relapsing/remitting (most common)
    • Relapse (days-months) followed by remission
  • Secondary progressive
    • Relapses and partial recoveries occur, but disability does not fade away between cycles
  • Primary progressive
    • Symptoms progress slowly and steadily without remission
  • Progressive relapsing
    • Similar to primary progressive but with superimposed flares

Clinical Features

  • Classic patient has multiple presentations for neuro symptoms of different areas of pathology
    • Patient often has resolution of the earlier symptoms
  • Symptoms worsen with increases in body temperature, classically after hot showers (Uhthoff's phenomenon[2])
  • Muscle/sensory signs:
    • Lower extremity weakness usually worse than upper extremity
    • Upper motor neuron signs:
      • Hyperreflexia
      • Positive Babinski
    • Decrease in proprioception/pain/temperature sensation
    • Lhermitte sign
      • Electric shock sensation radiating down back into arms/egs from neck flexion
      • If the discomfort is severe, carbamazepine or gabapentin may be beneficial for some patients.
  • Optic neuritis
  • Internuclear ophthalmoplegia
    • Abnormal eye adduction bilaterally and horizontal nystagmus
    • Convergence (both eyes center medially) is preserved
  • Dysautonomia

Differential Diagnosis

Weakness

Evaluation

MRI brain with contrast of a patient in her mid-20s with new onset MS. Large lesion in left parietal area.
MRI brain with contrast of same patient with new onset MS with another lesion in the left cerebellum.
  • CSF
    • Elevated protein and gamma-globulin (increased oligoclonal bands)
  • MRI
    • Multiple lesions in supratentorial white matter, paraventricular area, spinal cord
  • MRI with GAD of brain (+/- spine) and orbits (if optic neuritis suspected)
  • CBC, Chemistry
  • Urinalysis

Management

  • Fever must be reduced to minimize weakness associated with elevated temperature

Infection Treatment

  • Antibiotics or surgical control of any infectious sources

Steroids and Immunomodulators

  • High-dose steroid therapy for relapses in the form of oral or intravenous methylprednisolone (1000 mg)[3]
  • Suppression therapies
    • IFN B, Glatiramer, Estriol (usually not in ED)

Disposition

  • Hospitalization indicated for:
    • Any disease exacerbation associated with significant morbidity
    • IV antibiotics or steroid therapy required
    • Depression and significant risk of suicide

See Also

References

  1. ↑ Multiple sclerosis: a practical overview for clinicians. British Medical Bulletin, Volume 95, Issue 1, September 2010, Pages 79–104. https://doi.org/10.1093/bmb/ldq017
  2. ↑ Flensner G, et al. "Sensitivity to heat in MS patients: a factor strongly influencing symptomology-an explorative survey". BMC Neurol. 2011. 11:27.
  3. ↑ Le Page et al. Oral versus intravenous high-dose methylprednisolone for treatment of relapses in patients with multiple sclerosis (COPOUSEP): a randomised, controlled, double-blind, non-inferiority trial. Lancet. 2016 Jan 23;387(10016):340. https://core.ac.uk/download/pdf/52993687.pdf
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