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July 2007
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25
July
2007

Multiple Sclerosis

Multiple Sclerosis (MS) is a disease of the central nervous system of unknown cause. The nerves are damaged through inflammation, probably the immune system attacking the sheaths of the nerves. It is #1 nontraumatic cause of disability in young adults. On average it afflicts people aged 15-50years old. Women are 2x more affected then men. 350,000 American have it, in particular those of Northern European descent. On the other hand 11% of MS patients at Johns Hopkins in Baltimore are African American.

Autoimmune? It is thought the immune system attacks an infection, say a virus such as human herpesvirus 6 or EBV, but then mistakenly attacks the coating of the nerves (myelin) as well. After enough nerves are damaged, the symptoms of MS appear and as well are detected on MRI. When the nerves can transmit signals to the body, muscles and organs are affected. And the brain lesions that form lead to fatigue, depression, and poor memory. After enough inflammatory attacks of the nerves, the nerves can eventually be permanently damaged.

Symptoms include fatigue and depression which often occur early. Because MS destroys the function of nerves, so numbness, tingling (parathesias), and weakness can result. Loss of vision in one eye or double vision, heat sensitivity, Lhermitte’s sign (feeling electricity shoot down the spine when flexing the neck), tremor, imbalance, poor movement & coordination, vertigo are more symptoms of MS. Bladder problems are common – either losing control to have incontinence or the opposite – retention. Also sexual problems can develop. A person with MS might only have a few symptoms which makes diagnosis difficult.

There are a lot of diseases that have similar symptoms as mentioned above, so making the diagnosis of MS can be a challenge. And on the flip side, people who don’t have MS often freak out thinking they have MS when really it is a different problem, such as B12 deficiency, Lyme disease, diabetes complications, etc.

Types of MS: 4 types are described: Relapsing-Remitting MS (RRMS), Secondary-Progressive MS (SPMS), Primary-Progressive MS (PPMS), and Progressive-Relapsing MS (PPMS).

RRMS: #1 type of the 4 – 80% of all MS patients at onset of MS flair. 55% of all MS patients at any given time (prevalence). The course of RRMS will be frequent attacks followed by remyelination (recovery of the damaged nerves) though permanent damage occurs over a matter of time. So disability occurs in a stepwise fashion gradually going downhill.

SPMS is the end result of RRMS due to long-term damage to the nervous system. With or without MS flairs, the nerves slowly die off leading the person with MS down a hard road of disability. 30% of all MS patients are in SPMS stage

PPMS means MS symptoms progress without any obvious relapses. No acute flairs but a gradual decline in function.

PRMS is rare, only 5% in which MS progresses without flairs, but even more so with flairs. No remitting.

Diagnosis: MRI of the brain is the best way in light of clinical symptoms. White plaques are seen in the white matter of the brain and in the spinal cord. Unfortunately, there are over a dozen infections that can mimic MS on the MRI.

In my experience, neurologists often don’t have a clear cut diagnosis of MS. In 2000, two MS societies convened to re-define the criteria to diagnose MS. In their meeting they said 1 clinical episode of an MS flair followed by detection of new lesions on MRI 3 months later is considered MS. This criteria is more stringent than before.

Lumbar puncture to evaluate the CSF (cerebral spinal fluid) can aide in diagnosis MS, in particular oligoclonal bands. But the sensitivity is pretty low early in the course of MS.

Evoked potential tests are also used to aide in diagnosis.

Treatment: the mainstay class of drugs is IFNb (interferon beta) and glatiramer acetate for RRMS. Avonex is IFNb-1a. IFNb-1a and 1b and glatiramer acetate are FDA approved for RRMS and has been clinically proven to reduce the frequency & severity of relapses. Will it prevent disability in the future? Probably but not for sure.

Mitoxantrone is chemotherapeutic in SPMS, PRMS, or worsening RRMS. But because it is toxic to the heart, it can only be used 2-3 years. Also leukemia can develop

Natalizumab is a monoclonal antibody that is being studied

Management: for me as PCP, persons with MS do tend to ignore their overall health, such as PAP smears, cholesterol, exercise, diet. Also with disability, osteoporosis can develop as well as bed sores. So I look out for all these things. Also depression and fatigue greatly affect the quality of life so antidepressants for mood and stimulants for energy can be used.

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