Multiple sclerosis (MS) Dr. Osman Sadig Bukhari
<ul><li>MS: </li></ul><ul><li>- Demyelinating dis within za brain and  spinal cord and never affects peripheral  nerves. <...
<ul><li>Aetiology : </li></ul><ul><li>1- unknown </li></ul><ul><li>2- likely to be multifactorial </li></ul><ul><li>- envi...
<ul><li>3- Immunological : there is increased </li></ul><ul><li>activated T lymphocytes  & anti viral Abs </li></ul><ul><l...
<ul><li>Pathology </li></ul><ul><li>-  demyelinating dis </li></ul><ul><li>-  Predeliction to  peri ventricular region, op...
<ul><li>Clinical features </li></ul><ul><li>Tow patterns: </li></ul><ul><li>1-  Relapsing & Remitting MS  (70-8%). Lesions...
<ul><li>Presentation </li></ul><ul><li>Symptoms & signs in za CNS referring to diff </li></ul><ul><li>sites occur at diff ...
<ul><li>4-  Sensory presentation : loss of proprioception </li></ul><ul><li>and light touch wz Lhermitte’s phenomenon </li...
<ul><li>Investigations & diagnosis </li></ul><ul><li>-  Clinical diag  depends on demonstration  of  </li></ul><ul><li>les...
<ul><li>Diff diagnosis </li></ul><ul><li>1- Thromboembolic stroke  2- syphilis </li></ul><ul><li>3- B12 def  4- Spinal cor...
<ul><li>Management of MS </li></ul><ul><li>- inform pt about diag when certain & discuss </li></ul><ul><li>employment, hom...
<ul><li>- Cryotherapy, radiotherapy, PPD, transfer </li></ul><ul><li>factor, gluten free diet, electric stimulatio </li></...
<ul><li>Course & prognosis </li></ul><ul><li>It is difficult to predict za course o MS, but </li></ul><ul><li>1- frequent ...
<ul><li>5- in later stages za pat may be greatly </li></ul><ul><li>disabled wz spastic paraparesis, ataxia, </li></ul><ul>...
<ul><li>Acute transverse myelitis </li></ul><ul><li>It is acute monophasic inflamm demyelinating </li></ul><ul><li>disorde...
<ul><li>Acute disseminated </li></ul><ul><li>encephalo myelitis </li></ul><ul><li>This is acute perivenous demyelination w...
<ul><li>- MRI  widespread demyelination </li></ul><ul><li>- CSF is normal or wz increased cells and </li></ul><ul><li>prot...
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Multiple Sclerosis

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Multiple Sclerosis

  1. 1. Multiple sclerosis (MS) Dr. Osman Sadig Bukhari
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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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