Multiple sclerosis: Difference between revisions
No edit summary
(27 intermediate revisions by 8 users not shown)
Line 6: Line 6:
**Relapse (days-months) followed by remission
**Relapse (days-months) followed by remission
*Secondary progressive  
*Secondary progressive  
**Relapses and partial recoveries occur, but disability doesn't fade away between cycles
**Relapses and partial recoveries occur, but disability does not fade away between cycles
*Primary progressive
*Primary progressive
**Symptoms progress slowly and steadily without remission
**Symptoms progress slowly and steadily without remission
Line 13: Line 13:


==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]]
**Afferent pupillary defect is pathognomonic for optic neuritis
**[[Nystagmus]]
**[[Diplopia]]
**[[Diplopia]]
*Internuclear ophthalmoplegia
*[[Internuclear ophthalmoplegia]]
**Abnormal eye adduction bilaterally and horizontal nystagmus
**Abnormal eye adduction bilaterally and horizontal nystagmus
**Convergence (both eyes center medially) is preserved
**Convergence (both eyes center medially) is preserved
*Dysautonomia
*Dysautonomia
**Urinary retention (increased risk of UTI/pyelo)
**[[Urinary retention]] (increased risk of [[UTI]]/[[pyelo]])
**Constipation or incontinence
**[[Constipation]] or incontinence
**Sexual dysfunction (males)
**Sexual dysfunction (males)


Line 41: Line 43:
{{Weakness DDX}}
{{Weakness DDX}}


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


==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
*Antibiotics for UTI/pyelo
*High-dose steroid therapy for relapses
*High-dose [[Corticosteroids|steroid]] therapy for relapses
*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


Line 82: Line 73:


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


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

Revision as of 04:03, 3 October 2019

Background

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

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[1])
  • 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

  • CSF
    • Elevated protein and gamma-globulin (increased oligoclonal bands)
  • MRI
    • Multiple lesions in supratentorial white matter, paraventricular area, spinal cord

  • 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.

Management

  • Fever must be reduced to minimize weakness associated with elevated temperature
  • Antibiotics for UTI/pyelo
  • High-dose steroid therapy for relapses
  • 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. ↑ Flensner G, et al. "Sensitivity to heat in MS patients: a factor strongly influencing symptomology-an explorative survey". BMC Neurol. 2011. 11:27.
Retrieved from "https://www.wikem.org/w/index.php?title=Multiple_sclerosis&oldid=231748"