Multiple sclerosis

Background

1. CNS myelin destruction causes variable motor, sensory, visual and cerebellar dysfunction
2. Types
   1. Relapsing/remitting (most common)
      1. Relapse (days-months) followed by remission
   2. Secondary progressive
      1. Relapses and partial recoveries occur, but disability doesn't fade away between cycles
   3. Primary progressive
      1. Symptoms progress slowly and steadily without remission
   4. Progressive relapsing
      1. Similar to primary progressive but with superimposed flares

Clinical Features

1. Classic pt has multiple presentations for neuro symptoms of different areas of pathology
   1. Pt often has resolution of the earlier symptoms
2. Symptoms worsen w/ increases in body temperature
3. Muscle/sensory signs:
   1. Lower extremity weakness usually worse than upper extremity
   2. Upper motor neuron signs:
      1. Hyperreflexia
      2. Positive Babinski
   3. Decrease in proprioception / pain/temp sensation
   4. Lhermitte sign
      1. Electric shock sensation radiating down back into arms/egs from neck flexion
4. Optic neuritis
   1. Initial sign in 30% of pts
   2. Vision loss (usually unilateral) often preceded by retrobulbar pain
   3. Blurred vision
   4. Nystagus
   5. Diplopia
   6. Internuclear ophthalmoplegia
      1. Abnormal eye adduction bilaterally and horizontal nystagmus
5. Dysautonomia
   1. Urinary retention (increased risk of UTI/pyelo)
   2. Constipation or incontinence
   3. Sexual dysfunction (males)

Diagnosis

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

DDX

1. SLE
2. Lyme disease
3. Neurosyphilis
4. HIV
5. Guillain-Barre syndrome

Work-Up

1. LP
   1. IgG
   2. Albumin
   3. Oligoclonal bands
   4. myelin basic protein
   5. Cell count
   6. Glucose
   7. Protein
   8. Gm stain
2. CBC, Chemistry
3. UA
4. MRI w/ GAD of brain (+/- spine)

Treatment

1. Fever must be reduced to minimize weakness a/w elevated temperature
2. Abx for UTI/pyelo
3. High-dose steroid therapy for relapses

Disposition

1. Hospitalization indicated for:
   1. Any disease exacerbation a/w significant morbidity
   2. IV abx or steroid therapy required
   3. Depression and significant risk of suicide

See Also

Optic Neuritis

Source

Tintinalli