A case of multiple sclerosis

1. A CASE OF MULTIPLE SCLEROSIS :
Follow Up Since 1997
Dr. L. K. Malhotra
MBBS, MD, DM (Neurology)
Consultant Neurologist
New Delhi, India

2. A CASE OF MULTIPLE SCLEROSIS : Follow Up
Since 1997
BACKGROUND
• Tertiary neurocentre : 0-2 new patients of
MS/ yr
• Majority patients have no insurance cover
• Patient can consult any neurologist
throughout India anytime

3. A CASE OF MULTIPLE SCLEROSIS : Follow Up
Since 1997
• 22 yrs Female SM
• On 22/7/97 H/O Acute onset ataxia
without headache, vomiting, fever, tinnitus,
deafness
• No past H/O fever, immunization, rash,
visual loss. H/O myocarditis in childhood.
No DOE
• O/E : Fundus normal, Gait ataxia, brisk
jerks, extensor plantars

4. A CASE OF MULTIPLE SCLEROSIS : Follow Up
Since 1997
• Investigations : Haemogram, Blood sugar,
liver, renal function tests, Rheumatoid
factor, ANF, DsantiDNA Ab, Se B12 levels,
ECG, X - ray chest ---- normal
• HIV and VDRL ---- negative
• CSF : cytology : 20 cells L, Proteins : 80
mg, sugar : 40mg, oligoclonal bands
----negative
• VEP : 112 ms ----- bilateral

5. SM 31 / 7 / 1997

6. SM 31 / 7 / 1997

7. SM 31 / 7 / 1997

8. A CASE OF MULTIPLE SCLEROSIS : 17 YEARS
FOLLOW-UP
• Treatment : I.V. -- M.P. 5 g followed by
oral steroids for 2 weeks
• Clinical and radiological improvement
seen

9. SM 11 / 10 / 1997

10. SM 11 / 10 / 1997

11. SM 17 / 3 / 1998

12. SM 9 / 3 / 1999

13. SM 9 / 3 / 1999

14. A CASE OF MULTIPLE SCLEROSIS : Follow Up
Since 1997
• Oct 2000 : worsening of ataxia
• MRI brain : Fresh brain stem and supra
tentorial lesions
• Treatment : I.V. M.P. 5 g
• Partial Improvement

15. A CASE OF MULTIPLE SCLEROSIS : Follow Up
Since 1997
• Nov 2000 : started on Avonex

16. A CASE OF MULTIPLE SCLEROSIS : Follow Up
Since 1997
• Aug 2001 : Worsening of ataxia, Tremulousness
on standing, limb ataxia
• MRI brain : fresh lesion in medulla
• Treatment : I.V. M.P. 3 g, Azathioprine added.
• Partial improvement

17. SM 17 / 8 / 2001

18. A CASE OF MULTIPLE SCLEROSIS : Follow Up
Since 1997
• Sept 2002 : worsening of ataxia,
dysarthria, gaze evoked nystagmus, limb
and gait ataxia, brisk jerks, plantar
extensors.
• MRI brain : fresh brain stem lesion
• Treatment : I.V. M.P 3 g

19. SM 18 / 9 / 2002

20. A CASE OF MULTIPLE SCLEROSIS : Follow Up
Since 1997
• April 2003 : worsening of symptoms. Oral
steroids for 3 weeks minimal improvement
• July 2003 : worsening of symptoms. Oral
steroids started. No improvement.
• MRI Brain : fresh parasaggital lesion
• MRI cervical and dorsal spine : sub acute
to chronic plaque seen.
• I.V. M.P. 3 g, no improvement

21. SM 23 / 4 / 2003

22. SM 25 / 7 / 2003

23. SM 25 / 7 / 2003

24. SM 25 / 7 / 2003

25. A CASE OF MULTIPLE SCLEROSIS : Follow Up
Since 1997
• Aug 2003 : dysarthric, gaze evoked
nystagmus, limb and gait ataxia, ankle
clonus, brisk jerks, extensor plantars
• Needed support to walk.
• RRMS SPMS

26. A CASE OF MULTIPLE SCLEROSIS : Follow Up
Since 1997
SUMMARY
• 22 yrs Female
• 7 / 1997 : First attack --- I.V. M.P.
• 10/2000 : Second attack --- I.V. M.P.
• 11/2000 : Avonex started
• Relapses : Aug 2001, Sep 2002, Apr 2003,
Jul 2003 Progressive course
• Aggressive Disease since Sep 2002

27. A CASE OF MULTIPLE SCLEROSIS : Follow Up
Since 1997
Treatment options :
• Mitoxantrone
• Cyclophosphamide
• I.V. MethylPrednisolone monthly
• I.V. Immunoglobulins
• G.A.
• Injection Rebif

28. A CASE OF MULTIPLE SCLEROSIS : Follow Up
Since 1997
Pulse therapy
• I.V. cyclophosphamide with I.V. high dose steroids
• Cyclophosphamide 1000 mg/m2 /course
(approx. 1500-2000 mg for average person)
• I.V. Methylprednisolone 750 mg BD or
Dexamethasone 150 mg BD
• Monitor blood counts, urine, X-ray chest, ECG
• Anti – emetics before cyclophosphamide
• Hydration I.V. / oral

29. A CASE OF MULTIPLE SCLEROSIS : Follow Up
Since 1997
PULSE THERAPY
1. 27 Oct 2003 --------- 6 weeks
2. 08 Dec 2003 --------- 6 weeks
3. 13 Jan 2004 --------- 6 weeks
4. 03 Mar 2004 --------- 2 months
5. 05 May 2004 --------- 2 months
6. 06 Jul 2004 --------- 4 months
7. 13 Nov 2004

30. A CASE OF MULTIPLE SCLEROSIS : Follow Up
Since 1997
• No urinary / menstrual problem. Mild
alopecia.
• Injection Rebif 22 microgm thrice a week
since Nov 2004 till now.
• And no relapse since then.

31. SM 10 / 2 / 2006

32. SM 10 / 2 / 2006

33. SM 10 / 2 / 2006

34. SM 10 / 2 / 2006