Multiple sclerosis: Difference between revisions
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==Background== | ==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 doesn't 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== | ==Clinical Features== | ||
*Classic pt has multiple presentations for neuro symptoms of different areas of pathology | |||
**Pt 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>) | |||
*Muscle/sensory signs: | |||
**Lower extremity weakness usually worse than upper extremity | |||
**Upper motor neuron signs: | |||
***Hyperreflexia | |||
***Positive Babinski | |||
**Decrease in proprioception / pain/temp sensation | |||
**Lhermitte sign | |||
***Electric shock sensation radiating down back into arms/egs from neck flexion | |||
*Optic neuritis | |||
**Initial sign in 30% of pts | |||
**Vision loss (usually unilateral) often preceded by retrobulbar pain | |||
**Blurred vision | |||
**Nystagus | |||
**[[Diplopia]] | |||
**Internuclear ophthalmoplegia | |||
***Abnormal eye adduction bilaterally and horizontal nystagmus | |||
*Dysautonomia | |||
**Urinary retention (increased risk of UTI/pyelo) | |||
**Constipation or incontinence | |||
**Sexual dysfunction (males) | |||
==Diagnosis== | ==Diagnosis== | ||
*MRI | |||
**Multiple lesions in supratentorial white matter, paraventricular area, spinal cord | |||
*CSF | |||
**Elevated protein and gamma-globulin (increased oligoclonal bands) | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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==Work-Up== | ==Work-Up== | ||
*LP | |||
**IgG | |||
**Albumin | |||
**Oligoclonal bands | |||
**myelin basic protein | |||
**Cell count | |||
**Glucose | |||
**Protein | |||
**Gm stain | |||
*CBC, Chemistry | |||
*UA | |||
* MRI w/ GAD of brain (+/- spine) | |||
==Treatment== | ==Treatment== | ||
*Fever must be reduced to minimize weakness assoc w/ elevated temperature | |||
*Abx for UTI/pyelo | |||
*High-dose steroid therapy for relapses | |||
==Disposition== | ==Disposition== | ||
*Hospitalization indicated for: | |||
**Any disease exacerbation a/w significant morbidity | |||
**IV abx or steroid therapy required | |||
**Depression and significant risk of suicide | |||
==See Also== | ==See Also== | ||
Revision as of 13:23, 20 July 2015
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 doesn't fade away between cycles
- Primary progressive
- Symptoms progress slowly and steadily without remission
- Progressive relapsing
- Similar to primary progressive but with superimposed flares
- Relapsing/remitting (most common)
Clinical Features
- Classic pt has multiple presentations for neuro symptoms of different areas of pathology
- Pt often has resolution of the earlier symptoms
- Symptoms worsen w/ increases in body temperature (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/temp sensation
- Lhermitte sign
- Electric shock sensation radiating down back into arms/egs from neck flexion
- Optic neuritis
- Initial sign in 30% of pts
- Vision loss (usually unilateral) often preceded by retrobulbar pain
- Blurred vision
- Nystagus
- Diplopia
- Internuclear ophthalmoplegia
- Abnormal eye adduction bilaterally and horizontal nystagmus
- Dysautonomia
- Urinary retention (increased risk of UTI/pyelo)
- Constipation or incontinence
- Sexual dysfunction (males)
Diagnosis
- MRI
- Multiple lesions in supratentorial white matter, paraventricular area, spinal cord
- CSF
- Elevated protein and gamma-globulin (increased oligoclonal bands)
Differential Diagnosis
Weakness
- Neuromuscular weakness
- Upper motor neuron:
- CVA
- Hemorrhagic stroke
- Multiple sclerosis
- Amyotrophic Lateral Sclerosis (ALS) (upper and lower motor neuron)
- Lower motor neuron:
- Spinal and bulbar muscular atrophy (Kennedy's syndrome)
- Spinal cord disease:
- Infection (Epidural abscess)
- Infarction/ischemia
- Trauma (Spinal Cord Syndromes)
- Inflammation (Transverse Myelitis)
- Degenerative (Spinal muscular atrophy)
- Tumor
- Peripheral nerve disease:
- Neuromuscular junction disease:
- Muscle disease:
- Rhabdomyolysis
- Dermatomyositis
- Polymyositis
- Alcoholic myopathy
- Upper motor neuron:
- Non-neuromuscular weakness
- Can't miss diagnoses:
- ACS
- Arrhythmia/Syncope
- Severe infection/Sepsis
- Hypoglycemia
- Periodic paralysis (electrolyte disturbance, K, Mg, Ca)
- Respiratory failure
- Emergent Diagnoses:
- Symptomatic Anemia
- Severe dehydration
- Hypothyroidism
- Polypharmacy
- Malignancy
- Aortic disease - occlusion, stenosis, dissection
- Other causes of weakness and paralysis
- Acute intermittent porphyria (ascending weakness)
- Can't miss diagnoses:
Work-Up
- LP
- IgG
- Albumin
- Oligoclonal bands
- myelin basic protein
- Cell count
- Glucose
- Protein
- Gm stain
- CBC, Chemistry
- UA
- MRI w/ GAD of brain (+/- spine)
Treatment
- Fever must be reduced to minimize weakness assoc w/ elevated temperature
- Abx for UTI/pyelo
- High-dose steroid therapy for relapses
Disposition
- Hospitalization indicated for:
- Any disease exacerbation a/w significant morbidity
- IV abx or steroid therapy required
- Depression and significant risk of suicide
See Also
Source
Tintinalli
- ↑ Flensner G, et al. "Sensitivity to heat in MS patients: a factor strongly influencing symptomology-an explorative survey". BMC Neurol. 2011. 11:27.