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Updated: Aug 1 2023

Multiple Sclerosis

  • 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
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