Snapshot A 32-year-old women presents to her physician complaining of double vision. This has been very distressing for her. She has a past medical history significant for type 1 diabetes, treated with a continuous subcutaneous insulin pump. Upon further questioning, she mentions she experienced arm weakness and numbness that resolved spontaneously over the course of a couple weeks. Physical examination is notable for impaired adduction of the right eye, and nystagmus on abduction of the left eye on left lateral gaze. Introduction Autoimmune inflammation/demyelination of CNS neurons destruction of oligodendrocytes mediated by CD8 T-cells and Th1/Th17 helper T cells specific anti-MBP (myelin basic protein) antibodies can find ↑ protein (IgG) in CSF over time white matter plaques accumulate in the brain and the spinal cord Epidemiology gender bias ↑ in women race bias ↑ in whites onset commonly between 20-40 years ↑ in temperate climates associated with HLA-DR2 Presentation Symptoms - may have multiple neurologic symptoms separated in time and space motor involvement hemiparesis MLF syndrome → internuclear ophthalmoplegia nystagmus scanning speech (sound intoxicated) intention tremor sensory involvement hemisensory symptoms heat sensitivity ("Uhthoff phenomenon") a temporary worsening of symptoms when exposed to increases in temperature optic neuritis sudden loss of vision afferent pupilary defect (Marcus Gunn pupil) autonomic involvement bladder/bowel incontinence Evaluation LP ↑ leukocytes ↑ γ-globulins results in oligoclonal banding ↑ MBP normal glucose Imaging must include two demyelinating lesions separated in time and space MRI is gold standard hyperintense on T2 and FLAIR with enhancement of acute lesions demyelinating periventricular plaques known as Dawson's fingers may have preservation (early) or destruction (late) of axons within plaques Differential Acute disseminated encephalomyelitis Neuromyelitis optica (NMO) Idiopathic transverse myelitis Treatment Medical β-interferon high-dose steroids (dexamethasone) speed recovery of ocular symptoms but do not change overall progression of disease glatiramer natalizumab ↑ risk of progressive multifocal leukoencephalopathy rituximab ↑ risk of progressive multifocal leukoencephalopathy Symptomatic treatment for neurogenic bladder, spasticity, and pain Prognosis, Prevention, and Complications Can exhibit multiple patterns of disability progression primary progressive - steady decline in function over time relapsing remitting - periods of relative stability alternating with declines secondary progressive - relatively stable at first followed by steady decline