Multiple sclerosis: Difference between revisions

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==Neuro Work-Up==
==Background==
# LP
*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>
##IgG
 
##albumin
===Types===
##IgG synthesis rate
*'''Relapsing/remitting (most common)'''
##oligoclonal bands
**Relapse (days-months) followed by remission
##myelin basic protein
*'''Secondary progressive'''
##cell count
**Relapses and partial recoveries occur, but disability does not fade away between cycles
##glucose
*'''Primary progressive'''
##protein
**Symptoms progress slowly and steadily without remission
##gm stain
*'''Progressive relapsing'''
# CBC, Chem 7, UA
**Similar to primary progressive but with superimposed flares
# ECG, CXR
 
# MRI w/ GAD of brain (+/- affected spine)
==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<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:
**Lower extremity [[weakness]] usually worse than upper extremity
**Upper motor neuron signs:
***Hyperreflexia
***Positive Babinski
**[[numbness|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]]
**Initial sign in 30% of patients
**[[Vision loss]] (usually unilateral) often preceded by retrobulbar pain
**[[Blurred vision]]
**Afferent pupillary defect is suggestive of optic neuritis
**[[Nystagmus]]
**[[Diplopia]]
*[[Internuclear ophthalmoplegia]]
**Abnormal eye adduction bilaterally and horizontal nystagmus
**Convergence (both eyes center medially) is preserved
*Dysautonomia
**[[Urinary retention]] (increased risk of [[UTI]]/[[pyelo]])
**[[Constipation]] or incontinence
**Sexual dysfunction (males)
 
==Differential Diagnosis==
{{Weakness DDX}}
 
==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]]
**Elevated protein and gamma-globulin (increased oligoclonal bands)
*[[brain MRI|MRI]]
**Multiple lesions in supratentorial white matter, paraventricular area, spinal cord
*[[brain MRI|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 [[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==
*Hospitalization indicated for:
**Any disease exacerbation associated with significant morbidity
**IV antibiotics or steroid therapy required
**Depression and significant risk of suicide


==See Also==
==See Also==
Optho: Optic Neuritis
*[[Optic Neuritis]]


==Source==
==References==
2/26/06 DONALDSON
<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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