Multiple sclerosis - Revision history

Danbot: Strip excess bold

2026-03-22T09:26:21Z

Strip excess bold

← Older revision		Revision as of 09:26, 22 March 2026
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	*More common in populations of Northern European descent and at higher latitudes		*More common in populations of Northern European descent and at higher latitudes
	===Types===		===Types===
	*~~'''~~Clinically isolated syndrome (CIS)~~'''~~		*Clinically isolated syndrome (CIS)
	**Single first episode of neurologic symptoms lasting ≥24 hours, caused by CNS demyelination		**Single first episode of neurologic symptoms lasting ≥24 hours, caused by CNS demyelination
	**May or may not progress to MS		**May or may not progress to MS
	*~~'''~~Radiologically isolated syndrome (RIS)~~'''~~		*Radiologically isolated syndrome (RIS)
	**Incidental MRI findings suggestive of MS in asymptomatic patients		**Incidental MRI findings suggestive of MS in asymptomatic patients
	*~~'''~~Relapsing/remitting (most common)~~'''~~		*Relapsing/remitting (most common)
	**Relapse (days-months) followed by remission		**Relapse (days-months) followed by remission
	*~~'''~~Secondary progressive~~'''~~		*Secondary progressive
	**Relapses and partial recoveries occur, but disability does not 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
	*~~'''~~Progressive relapsing~~'''~~		*Progressive relapsing
	**Similar to primary progressive but with superimposed flares		**Similar to primary progressive but with superimposed flares
	==Clinical Features==		==Clinical Features==
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	**Sexual dysfunction (males)		**Sexual dysfunction (males)
	*Other common symptoms		*Other common symptoms
	**~~'''~~Fatigue~~'''~~ — most common symptom overall; frequent reason for ED presentation		**Fatigue — most common symptom overall; frequent reason for ED presentation
	**Cognitive dysfunction (up to 50% of patients)		**Cognitive dysfunction (up to 50% of patients)
	==Differential Diagnosis==		==Differential Diagnosis==
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	*Temperature — fever suggests pseudorelapse or infection		*Temperature — fever suggests pseudorelapse or infection
	*[[brain MRI\|MRI]] with GAD generally not needed emergently unless diagnostic uncertainty or concern for [[PML]]		*[[brain MRI\|MRI]] with GAD generally not needed emergently unless diagnostic uncertainty or concern for [[PML]]
	*LP is generally ~~'''~~not~~'''~~ needed for exacerbation of known MS — defer to neurology		*LP is generally not needed for exacerbation of known MS — defer to neurology

	===Suspected New Diagnosis===		===Suspected New Diagnosis===
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	*~~'''~~Always check UA and infectious workup before initiating steroids~~'''~~ — occult UTI is a very common pseudorelapse trigger in MS patients		*Always check UA and infectious workup before initiating steroids — occult UTI is a very common pseudorelapse trigger in MS patients
	*If symptoms are identical to a prior relapse, pseudorelapse is more likely (MS rarely causes repeated inflammation in the same CNS location)		*If symptoms are identical to a prior relapse, pseudorelapse is more likely (MS rarely causes repeated inflammation in the same CNS location)
	*Symptoms that fluctuate or resolve completely and then return favor pseudorelapse<ref>Amin A, et al. "Triaging Patients with Multiple Sclerosis in the Emergency Department: Room for Improvement." Proc Bayl Univ Med Cent. 2022;36(2):186-189.</ref>		*Symptoms that fluctuate or resolve completely and then return favor pseudorelapse<ref>Amin A, et al. "Triaging Patients with Multiple Sclerosis in the Emergency Department: Room for Improvement." Proc Bayl Univ Med Cent. 2022;36(2):186-189.</ref>
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	===Steroids===		===Steroids===
	*High-dose [[Corticosteroids\|steroid]] therapy for ~~'''~~true relapses~~'''~~ in the form of oral or intravenous methylprednisolone (1000 mg daily x 3-5 days)<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>		*High-dose [[Corticosteroids\|steroid]] therapy for true relapses in the form of oral or intravenous methylprednisolone (1000 mg daily x 3-5 days)<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>
	**Oral methylprednisolone at equivalent doses is non-inferior to IV and allows for outpatient treatment		**Oral methylprednisolone at equivalent doses is non-inferior to IV and allows for outpatient treatment
	*Do ~~'''~~not~~'''~~ initiate steroids until infection has been ruled out as the cause of symptom worsening		*Do not initiate steroids until infection has been ruled out as the cause of symptom worsening

	===Plasma Exchange (PLEX)===		===Plasma Exchange (PLEX)===
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	===Disease-Modifying Therapies (DMTs)===		===Disease-Modifying Therapies (DMTs)===
	*Suppression therapies (IFN-β, Glatiramer, etc.) — initiation is generally ~~'''~~not~~'''~~ in ED		*Suppression therapies (IFN-β, Glatiramer, etc.) — initiation is generally not in ED
	*However, ED physicians should be aware of ~~'''~~complications of DMTs~~'''~~ in patients already on treatment:		*However, ED physicians should be aware of complications of DMTs in patients already on treatment:

	{\| class="wikitable"		{\| class="wikitable"

Ostermayer at 23:15, 28 February 2026

2026-02-28T23:15:44Z

Show changes

Rossdonaldson1: /* Evaluation */

2022-11-16T21:01:34Z

Evaluation

← Older revision		Revision as of 21:01, 16 November 2022
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	==Evaluation==		==Evaluation==
			[[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.]]
			[[File:MS_MRI_2.jpg\|thumb\|MRI brain with contrast of same patient with new onset MS with another lesion in the left cerebellum.]]
	*[[LP\|CSF]]		*[[LP\|CSF]]
	**Elevated protein and gamma-globulin (increased oligoclonal bands)		**Elevated protein and gamma-globulin (increased oligoclonal bands)
	*[[brain MRI\|MRI]]		*[[brain MRI\|MRI]]
	**Multiple lesions in supratentorial white matter, paraventricular area, spinal cord		**Multiple lesions in supratentorial white matter, paraventricular area, spinal cord
	~~<gallery>~~
	~~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 left cerebellum.~~
	~~</gallery>~~
	*[[brain MRI\|MRI]] with GAD of brain (+/- spine) and orbits (if [[optic neuritis]] suspected)		*[[brain MRI\|MRI]] with GAD of brain (+/- spine) and orbits (if [[optic neuritis]] suspected)
	*CBC, Chemistry		*CBC, Chemistry

Ostermayer: /* Management */

2022-11-09T13:48:39Z

Management

← Older revision		Revision as of 13:48, 9 November 2022
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	==Management==		==Management==
	*Fever must be reduced to minimize weakness associated with elevated temperature		*Fever must be reduced to minimize weakness associated with elevated temperature
	*Antibiotics ~~for UTI/pyelo~~		===Infection Treatment===
	*High-dose [[Corticosteroids\|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		*Suppression therapies
	**IFN B, Glatiramer, Estriol (usually not in ED)		**IFN B, Glatiramer, Estriol (usually not in ED)

Ostermayer: /* Evaluation */

2022-11-09T13:36:48Z

Evaluation

← Older revision		Revision as of 13:36, 9 November 2022
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	File:MS_MRI_2.jpg\|MRI brain with contrast of same patient with new onset MS with another lesion in the left 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>
	*[[brain MRI\|MRI]] with GAD of brain (+/- spine)		*[[brain MRI\|MRI]] with GAD of brain (+/- spine) and orbits (if [[optic neuritis]] suspected)
	*CBC, Chemistry		*CBC, Chemistry
	*[[Urinalysis]]		*[[Urinalysis]]

Ostermayer: /* Background */

2022-11-09T13:17:52Z

Background

← Older revision		Revision as of 13:17, 9 November 2022
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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===		===Types===

Ostermayer: /* Types */

2022-11-09T13:16:12Z

Types

← Older revision		Revision as of 13:16, 9 November 2022
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	===Types===		===Types===
	*Relapsing/remitting (most common)		*'''Relapsing/remitting (most common)'''
	**Relapse (days-months) followed by remission		**Relapse (days-months) followed by remission
	*Secondary progressive		*'''Secondary progressive'''
	**Relapses and partial recoveries occur, but disability does not 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
	*Progressive relapsing		*'''Progressive relapsing'''
	**Similar to primary progressive but with superimposed flares		**Similar to primary progressive but with superimposed flares

Max.blodgett at 04:21, 29 November 2021

2021-11-29T04:21:24Z

← Older revision		Revision as of 04:21, 29 November 2021
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	**[[Vision loss]] (usually unilateral) often preceded by retrobulbar pain		**[[Vision loss]] (usually unilateral) often preceded by retrobulbar pain
	**[[Blurred vision]]		**[[Blurred vision]]
	**Afferent pupillary defect is ~~pathognomonic for~~ optic neuritis		**Afferent pupillary defect is suggestive of optic neuritis
	**[[Nystagmus]]		**[[Nystagmus]]
	**[[Diplopia]]		**[[Diplopia]]

Elcatracho: /* Clinical Features */

2021-03-06T10:24:28Z

Clinical Features

← Older revision		Revision as of 10:24, 6 March 2021
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	***Hyperreflexia		***Hyperreflexia
	***Positive Babinski		***Positive Babinski
	**[[numbness\|Decrease]] in proprioception / pain/temperature 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

ClaireLewis at 04:03, 3 October 2019

2019-10-03T04:03:15Z

← Older revision		Revision as of 04:03, 3 October 2019
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	*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>)		*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/temperature 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
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	*[[Optic neuritis]]		*[[Optic neuritis]]
	**Initial sign in 30% of patients		**Initial sign in 30% of patients
	**Vision loss (usually unilateral) often preceded by retrobulbar pain		**[[Vision loss]] (usually unilateral) often preceded by retrobulbar pain
	**Blurred vision		**[[Blurred vision]]
	**Afferent pupillary defect is pathognomonic for optic neuritis		**Afferent pupillary defect is pathognomonic for optic neuritis
	**~~Nystagus~~		**[[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
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	==Evaluation==		==Evaluation==
	~~===Work-Up===~~		*[[LP\|CSF]]
	*[[LP]]
	**IgG
	**Albumin
	**Oligoclonal bands
	**myelin basic protein
	**Cell count
	**Glucose
	**Protein
	**Gm stain
	*CBC, Chemistry
	*[[Urinalysis]]
	*[[brain MRI\|~~MRI~~]] ~~with GAD of brain (+/- spine)~~

	~~===Evaluation===~~
	*CSF
	**Elevated protein and gamma-globulin (increased oligoclonal bands)		**Elevated protein and gamma-globulin (increased oligoclonal bands)
	*[[brain MRI\|MRI]]		*[[brain MRI\|MRI]]
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	File:MS_MRI_2.jpg\|MRI brain with contrast of same patient with new onset MS with another lesion in the left 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>
			*[[brain MRI\|MRI]] with GAD of brain (+/- spine)
			*CBC, Chemistry
			*[[Urinalysis]]

	==Management==		==Management==