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Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
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Multiple Sclerosis

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  • 1. Multiple sclerosis (MS) Dr. Osman Sadig Bukhari
  • 2. <ul><li>MS: </li></ul><ul><li>- Demyelinating dis within za brain and spinal cord and never affects peripheral nerves. </li></ul><ul><li>- Common cause of long standing disability in Britain ,but rare in za tropics. </li></ul><ul><li>- Onset 20-40 years, rare before puberty and after 60. </li></ul><ul><li>- F> M </li></ul>
  • 3. <ul><li>Aetiology : </li></ul><ul><li>1- unknown </li></ul><ul><li>2- likely to be multifactorial </li></ul><ul><li>- enviromental: prevalence directly related </li></ul><ul><li>to za distance from za equator. More common </li></ul><ul><li>in temperate zones. Immigrants from low </li></ul><ul><li>to high prevalence before age of 15 year </li></ul><ul><li>acquire za prevalence of za country of </li></ul><ul><li>destination. </li></ul><ul><li>- genetic influence: 1 st degree relatives have </li></ul><ul><li>10 fold risk of developing za disease, high </li></ul><ul><li>concordance in monozygotics & positive associatio </li></ul><ul><li>between MS & certain types pf HLA. </li></ul>
  • 4. <ul><li>3- Immunological : there is increased </li></ul><ul><li>activated T lymphocytes & anti viral Abs </li></ul><ul><li>in CSF of pts wz MS. </li></ul><ul><li>There is increased synthesis of Ig within </li></ul><ul><li>CNS. </li></ul>
  • 5. <ul><li>Pathology </li></ul><ul><li>- demyelinating dis </li></ul><ul><li>- Predeliction to peri ventricular region, optic Ns, </li></ul><ul><li>brainstem & its cerebellar connections and za </li></ul><ul><li>spinal cord. </li></ul><ul><li>- Acute lesion is za plague wz swelling of axis </li></ul><ul><li>cylinder wz patchy infiltration wz inflamm cells </li></ul><ul><li>followed by: </li></ul><ul><li>- gliosis & scarring in chronic lesions. </li></ul>
  • 6. <ul><li>Clinical features </li></ul><ul><li>Tow patterns: </li></ul><ul><li>1- Relapsing & Remitting MS (70-8%). Lesions </li></ul><ul><li>occurring in diff parts of CNS at diff times, </li></ul><ul><li>affecting mainly optic N, brainstem, cerebell </li></ul><ul><li>and spinal cord. Few have one episodes </li></ul><ul><li>2- Slowly progressive MS : </li></ul><ul><li>- slowly progressive from za start (10-20) </li></ul><ul><li>- late progression after relapsing & remitting </li></ul><ul><li>course in a minority </li></ul><ul><li>- < 10% have fulminant course </li></ul>
  • 7. <ul><li>Presentation </li></ul><ul><li>Symptoms & signs in za CNS referring to diff </li></ul><ul><li>sites occur at diff times. </li></ul><ul><li>1- ocular presentations : pain, blurring of vision & in extreme cases loss of vision, retro bulbar neuritis and papilloedema, impaired pupillary reflexes and colour vision. </li></ul><ul><li>2- Pyramidal presentation : sub acute spastic paraparesis with ankle & patellar clonus, extensor planter, urgency of mict & retention. 3- Cerebellar features : ataxia, inco ordination, </li></ul><ul><li>nystagmus etc. </li></ul>
  • 8. <ul><li>4- Sensory presentation : loss of proprioception </li></ul><ul><li>and light touch wz Lhermitte’s phenomenon </li></ul><ul><li>(tingling in za spine & ULs on neck flexion) </li></ul><ul><li>5- Brain stem presentation : diplopia, vertigo, </li></ul><ul><li>facial numbness and/ or weakness, dysphagia </li></ul><ul><li>and pyramidal signs if C/S tracts involved. </li></ul><ul><li>6- Unusual presentation : epilepsy, trigeminal </li></ul><ul><li>neuralgia under 50ys, rec facial palsy, amnesi </li></ul><ul><li>psychosis & late dementia. </li></ul><ul><li>* symptoms may worsen wz febrile illness, hot </li></ul><ul><li>bath & after exercise. </li></ul>
  • 9. <ul><li>Investigations & diagnosis </li></ul><ul><li>- Clinical diag depends on demonstration of </li></ul><ul><li>lesions occurring at diff times & sites within </li></ul><ul><li>the CNS. </li></ul><ul><li>- Delayed visual, auditory & somatic evoked </li></ul><ul><li>potentials. </li></ul><ul><li>- MRI demonstrates plagues of demyelination </li></ul><ul><li>and is better than CT. </li></ul><ul><li>- CSF : lymphocytosis & oligoclonal band of IgG </li></ul><ul><li>produced locally. </li></ul>
  • 10. <ul><li>Diff diagnosis </li></ul><ul><li>1- Thromboembolic stroke 2- syphilis </li></ul><ul><li>3- B12 def 4- Spinal cord compression </li></ul><ul><li>5- Cervical myelopathy 6- Friedreich’s ataxia </li></ul><ul><li>7- SLE 8- Behcet’s 9- CNS sarcoidosis etc. </li></ul>
  • 11. <ul><li>Management of MS </li></ul><ul><li>- inform pt about diag when certain & discuss </li></ul><ul><li>employment, home & future plans. </li></ul><ul><li>- reassure about za benign natures of za disease </li></ul><ul><li>- Short courses of ACTH & C/S e.g. methyl predn </li></ul><ul><li>1g daily for 3 days reduce za severity of the </li></ul><ul><li>relapse, but do not influence za long term </li></ul><ul><li>outcome. </li></ul><ul><li>- Immunosuppression: e.g azathioprim and </li></ul><ul><li>cyclophos to prevent relapse </li></ul><ul><li>- Beta interferon reduces relapse rate & disability </li></ul><ul><li>but expensive. </li></ul>
  • 12. <ul><li>- Cryotherapy, radiotherapy, PPD, transfer </li></ul><ul><li>factor, gluten free diet, electric stimulatio </li></ul><ul><li>and hyperbaric O2 have been suggested </li></ul><ul><li>but proved ineffective. </li></ul><ul><li>- Spasticity: physiotherapy, baclofen </li></ul><ul><li>(15-100mg) & diazepam </li></ul><ul><li>- Ataxia: INH & clonazepam </li></ul><ul><li>- Dysaethesia: carbamazepine, phenytoin </li></ul><ul><li>and tricyclic anti depressants. </li></ul><ul><li>- Urinary troubles: probanthine, imipramin </li></ul><ul><li>bethancol, intermittent self catheterization & TR of UTI. </li></ul>
  • 13. <ul><li>Course & prognosis </li></ul><ul><li>It is difficult to predict za course o MS, but </li></ul><ul><li>1- frequent relapses wz incomplete recovery, </li></ul><ul><li>short interval between relapses & remissions, </li></ul><ul><li>onset wz brainstem & cerebellar involvement </li></ul><ul><li>are associated wz poor prognosis </li></ul><ul><li>2- early age of onset, optic neuritis & sensory </li></ul><ul><li>relapses have favourable prognosis </li></ul><ul><li>3- in minority, there is long interval between </li></ul><ul><li>attacks & 0n some there is no relapse e.g </li></ul><ul><li>optic neuritis, </li></ul><ul><li>4- slowly progressive spastic paraparesis may be the </li></ul><ul><li>only presentation. </li></ul>
  • 14. <ul><li>5- in later stages za pat may be greatly </li></ul><ul><li>disabled wz spastic paraparesis, ataxia, </li></ul><ul><li>optic atrophy, brainstem signs, pseudo- </li></ul><ul><li>bulbar palsy, incontinence of urine and </li></ul><ul><li>dementia. </li></ul><ul><li>6- 15% have only one episode </li></ul><ul><li>7- relapses usually occur every 2 years </li></ul><ul><li>8- 5% die within 5 years </li></ul><ul><li>9-CRF & chest infection are za commonest </li></ul><ul><li>cause of death. </li></ul><ul><li>10- after 15 years 50 need walking aids. </li></ul>
  • 15. <ul><li>Acute transverse myelitis </li></ul><ul><li>It is acute monophasic inflamm demyelinating </li></ul><ul><li>disorder affecting za spinal cord over several </li></ul><ul><li>segments at any age presenting with: </li></ul><ul><li>- flaccid paraparesis </li></ul><ul><li>- retention of urine </li></ul><ul><li>- sensory level </li></ul><ul><li>- back ache at za onset </li></ul><ul><li>- causes include MS, viral infection, syphilis, </li></ul><ul><li>radiation, ant spinal artery occlusion, </li></ul><ul><li>- CSF shows pleocytosis, MRI to exclude cord </li></ul><ul><li>compression </li></ul><ul><li>- High dose methylpredn for TR, but za outcome is </li></ul><ul><li>variable & small proportion go on to develop MS later. </li></ul>
  • 16. <ul><li>Acute disseminated </li></ul><ul><li>encephalo myelitis </li></ul><ul><li>This is acute perivenous demyelination widely </li></ul><ul><li>disseminated throughout za brain & spinal cord. </li></ul><ul><li>Causes : - idiopathic </li></ul><ul><li>- follows viral infection (measels, chickenpox) </li></ul><ul><li>and vaccination ?? Immunologically mediated. </li></ul><ul><li>Clinical features </li></ul><ul><li>- fever, headache, vomiting, meningism & confu </li></ul><ul><li>+/- focal or multifocal brain or spinal cord signs </li></ul><ul><li>seizures, flaccid paralysis, ext planter, ataxia, coma </li></ul>
  • 17. <ul><li>- MRI widespread demyelination </li></ul><ul><li>- CSF is normal or wz increased cells and </li></ul><ul><li>proteins </li></ul><ul><li>- Differentiation from 1 st severe attack </li></ul><ul><li>may be difficult </li></ul><ul><li>- Though disease may be fatal in za acute stage, it is self limitting. </li></ul>

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