Multipe Sclerosis or MS is one of the most common neurological causes of long term disability. MS has been elaborated in terrific and realistic manner even in movies. Many well-known persons have fallen for this disease and many have set examples for other people living with Multiple sclerosis.
More common among Females with Female : Male 2:1 ratio. It is more common in the Temperate zones of the Earth’s latitude.
Etiology or Cause:
- MS is caused by interplay of multiple genetic and environmental factors. Occurrence is higher in temperate zones, although no specific environmental factors have so far been co-related.
- Myelin producing of CNS are target of recurrent Cell-mediated Autoimmune attack. Associated with Class II MHC alleles and genes related to TNF- Alfa and HLA haplotypes.
- Familial recurrence rate is 15%
- Concordance in Monozygotic twins is 35%
- Entry of Activated T Lymphocytes through Blood-Brain-Barrier
- Recognition of Myelin derived Ag on surface of CNS’s Ag-presenting microglia
- Clonal proliferation
- Activation of Cascade of Cytokines
- Initiation of Destruction of Oligodendrocyte-myelin Unit by Macrophage .
- Optic Neuritis
- Relapsing and remitting sensory symptoms
- Subacute painless Spinal Cord Lesions
- Acute Brain Stem Syndrome
- 6th Cranial Nerve palsy or Abducens palsy
- RAPD and Optic Atrophy
- Lhermitte’s syndrome
- Progressive non-compressive paraparesis
- Partial Brown-sequard syndrome
- Intranulear Ophthalmoplegia with Ataxia
- Postural or Rubral Holmes tremor
- Trigeminal Neuralgia
- Recurrent Facial Palsy
Onset and Courses:
- Rarely before puberty or after 50s
- Peak incidence is in the 4th decades
- Symptoms come over days to week and resolve over weeks to months
4 patterns of Course has been seen in Multiple Sclerosis
- I -Relapsing and Remitting course-80% cases
- II -Fulminant course- 10% cases, In this type death occurs early
- III -Primary progressive -10-20%
- IV -Secondary Progressive
- Demonstration of Lesion in more than 1 site at more than 1 time for which there is no other explanation.
- Macdonald’s Criteria has been used for diagnosis
- MRI, Myelography to exclude other structural disease
- Visual Evoked Potential and other Evoked Potentials
- CSF examination- Cell count is high, Protein Electrophoresis o CSF- Oligoclonal bands
- To Exclude other diseases- Chest x ray, Serum ACE ( Sarcoidosis) , Antiphospholipid antibody and ANA ( SLE) and Serum B12 ( for B12 Deficiency)
- Acute Phase: High Dose of Methylprednisolone IV 1 gm for 3 days or
- Orally 500mg OD for 5 days
- Pulse Steroid can be given 3 times in a year
Treatment shortens the course and early prevention of relapse.
- Immunosuppressive agents – Azathioprine, Cyclophosphamide, Mitoxanthrone
- Immuno Modulators- Glatimer Acetate, IV Ig, Natalizumab ( Monoclonal Ab to B-intergrins)
Treatment Of Complications:
- Spasticity- Physiotherapy, Musle relaxants
- Ataxia- Isoniazid , Clonazepam
- Bladder Symptoms- CISC
- Dysaesthesia : Antidepressants, Phenytoin, Methyldopa
- Impotence: Sildenafil
- Fatigue- Amantadine, Modafinil, Amitriptylline
Prognosis- 50% are disabled by 15 years of Onset of the Disease