Case scenario of multiple sclerosis . Disease modification drugs. Ljermitte sign. Cerebellar sign. Uthoff phenomenon . Parkinsonism neurology neurosurgery. Cerebellar signs diseasSymptoms of MS vary from person to person and depend on the location and severity of nerve fibre damage. These often include vision problems, tiredness, trouble walking and keeping balance, and numbness or weakness in the arms and legs. Symptoms can come and go or last for a long time. The causes of MS are not known but a family history of the disease may increase the risk. While there is no cure for MS, treatment can reduce symptoms, prevent further relapses and improve quality of life.Disease course Most people with MS have a relapsing-remitting disease course. They experience periods of new symptoms or relapses that develop over days or weeks and usually improve partially or completely. These relapses are followed by quiet periods of disease remission that can last months or even years. Small increases in body temperature can temporarily worsen signs and symptoms of MS. These aren't considered true disease relapses but pseudorelapses. At least 20% to 40% of those with relapsing-remitting MS can eventually develop a steady progression of symptoms, with or without periods of remission, within 10 to 20 years from disease onset. This is known as secondary-progressive MS. The worsening of symptoms usuallyCauses The cause of multiple sclerosis is unknown. It's considered an immune mediated disease in which the body's immune system attacks its own tissues. In the case of MS, this immune system malfunction destroys the fatty substance that coats and protects nerve fibers in the brain and spinal cord (myelin). Myelin can be compared to the insulation coating on electrical wires. When the protective myelin is damaged and the nerve fiber is exposed, the messages that travel along that nerve fiber may be slowed or blocked. It isn't clear why MS develops in some people and not others. A combination of genetics and environmental factors appears to be responsible. Risk factors These factors may increase your risk of developing multiple sclerosis: Age. MS can occur at any age, but onset usually occurs around 20 and 40 years of age. However, younger and older people can be affected. Sex. Women are more than 2 to 3 times as likely as men are to have relapsing-remitting MS. Family history. If one of your parents or siblings has had MS, you are at higher risk of developing the disease. Certain infections. A variety of viruses have been linked to MS, including Epstein-Barr, the virus that causes infectious mononucleosis. Race. White people, particularly those of Northern European descent, are at highest risk of developing MS. People of Asian, African or Native American descent have the lowest risk. A recent study suggests that the number of Black and Hispanic young adults with multiple sclerosis may be greater than previously thought. Climate. MS is far more common in countries wit

1. Multiple Sclerosis
Collection of Case Studies

2. Case Study 1
● A male patient aged 44 years first experienced an
episode of acute vision loss at age 22. This episode
resolved without treatment over a two week period.
Then, at age 29, the patient experienced an episode of
transverse myelitis at spinal level T4. The patient was
hospitalized and underwent a CT scan, myelogram, and
cerebrospinal fluid (CSF) analysis, all with normal
findings. The patient was therefore diagnosed with likely
MS, which was not treated. This episode resolved with
minimal residual leg numbness. At age 44, after working
for years as a security guard, he was laid off due to an
oversight on the job. When he was unable to gain
alternative employment, DVR referred him to a
neurologist for a re-evaluation of his history of possible
MS.

3. Continuation…
● The patient had no additional attacks since age 29 and his
examination shows no physical disability. However MRI
scans showed multiple hyperintense lesions in the
periventricular white matter with moderate atrophy.
Continued work with DVR has established that the
patient has low employment potential due to cognitive
impairment; neuropsychological testing has been
ordered but the results are still pending. When shown his
MRI scan, the patient expressed a strong desire to begin
MS treatment. His health insurance is due to expire in
two months.

4. MRI compared to CT

5. Brain MRI in Multiple Sclerosis

6. Discussion Points
● What should be done to help this patient?
● Is he a candidate for DMTs?
● What programs or services are available to him?
● What is your long term plan?

7. Case Study 2
● An otherwise healthy 29 year old woman with a history of
migraines visited the Emergency Department with a severe
headache. He also had a history of intermittent paresthesias
of the face, hands, and feet which she thought might have
been brought on by stress. The patient reports the
occurrence of MS in her maternal aunt. Her general physical
and complete neurologic examination were normal. Her
brain MRI showed fairly extensive nonspecific T2
abnormalities throughout the deep subcortical white matter
without rounded or ovoid configuration. The corpus
callosum and posterior fossa were normal. None of the
lesions were juxtacortical or justaventricular. T1 scans
showed no hypointensities or enhancement with GD after a
five minute delay.

8. Not sure about this MRI Leny

9. Discussion Points
● Is this MS?
● What do you think is the problem?
● What additional assessments should you do as a
nurse?

10. Case Study 3
● A male patient age 35 is an executive who works 50-60
hours per week. He travels frequently. He was diagnosed
with MS 7 years ago and initially he had infrequent
exacerbations. He was treated with both oral and IV
steroids. Two years ago he developed bilateral lower
extremity weakness, a T10 sensory level, and forgetfulness.
Treatment with glatiramer acetate was initiated at that
time. Currently, the patient does not feel he is getting
better; therefore he administers GA intermittently.
Although he has difficulty with self-injection, he will not ask
his family for assistance. Over time he has become
increasingly anxious and isolated and his social and work
relationships have suffered.

11. Discussion Points
● What is your assessment of this patient?
● How can we help?
● What would be your initial recommendation?
● Follow-up?

12. Case Study 4
● Susan is a 24 year old woman with MS diagnosed three
years ago. She has been taking DMT for two years with an
inconsistent routine of injections and minimal healthcare
follow up. She lives with her boyfriend and they have a very
active lifestyle. She works full time and has a busy social life
getting 3-4 hours of sleep each night and eating irregularly.
Medications consist of DMT, OTC headache medications,
oral contraceptive, and Provigil 200 mg. bid. She presents at
your office complaining of nausea, vomiting, dizziness, and
severe fatigue. Neurologic examination is negative except
for a positive Romberg test. U/A via dipstick is positive for
leukocyte esterase. Vital signs BP 120/80; HR 100, lungs
clear. Patient is afebrile. LMP six weeks ago.

13. Discussion Points
● Is this a relapse? Pseudo relapse?
● UTI? What is the differential?
● What tests are indicated?

14. Case Study 5
● Charles is a 31 year old male who has been Copaxone
treatment for 3 years. He previously experienced 1-2
relapses annually; this has been reduced to less than 1 per
year. He lives alone and has intermittent assistance from a
community program. He complains of short term memory
problems and difficulty with ADL’s. The patient calls early
one Friday morning requesting a referral to a dentist. He
states that he has had facial pain for about one week and
needs to see a dentist. When questioned by the nurse, it
was determined that the pain emanates from his ear to his
chin and is worse at night.

15. Discussion Points
● What is your assessment?
● What treatment should be initiated?
● Does the patient need a dentist?
● MRI?

16. Case Study 6
● Patty is 32 years old. She works full time as a nurse. She is
married with one child. She has had MS for 10 years and is
on an injectable therapy. Her MRI is positive for 9
hyperintense lesions, 2 enhancing lesions, and one
infratentorial lesion. She has been feeling more fatigue
lately and her legs are very stiff. She does not take any
medications for her fatigue or stiffness. She presents at
your clinic asking about the risks if she stops her therapy
and becomes pregnant.

17. T2 Weighted Images
Conventional T2 FLAIR
Fluid Attenuated Inversion Recovery

18. Discussion Points
● What is your assessment?
● What are her primary needs at this time?

19. Case Study 7
● A 34 year old woman was diagnosed in 1992 and presents
for further help in your office. Initially she experienced a
relapsing-remitting course with mild and infrequent
exacerbations. However, several years later she had a
severe attacks that left her with paralysis of both legs and
bladder retention. After discharge from a rehabilitation
facility, she required a walker and motorized tricart for
mobility. Her current symptom management includes
amantidine for fatigue, oxybutynin chloride for bladder
urgency and frequency, and methanamine hippurate to
improve urine acidity. The takes gabapentin for pain and
has counseling, rehabilitation, and support group services to
help her cope with her ongoing disability. She presents at
your practice requesting treatment with disease modifying
therapy since her support group has urged her to consider
this; they stated that “it is not too late for you.”

20. Discussion Points
● What would you recommend at this time?
● How can you help this patient realistically?

21. More Challenging Cases

22. Case Study 8
● Cindy is a 34 year old woman who was diagnosed with MS
two years ago. She is on an injectable medication and is
very adherent to the protocol. She feels fine in the morning
but in the afternoon her walking worsens and she is subject
to fatigue. She heard that dalfampridine is now available
and she has decided to stop her injections and ask for a
prescription for this oral therapy. Her reason is that her
insurance has an annual limit and she prefers to spend her
insurance dollars to help her to walk better.
● You are a nurse practitioner/PA in her MS Center. The
neurologist has refused to give her a prescription for
dalfampridine and now Cindy is requesting her records so
she can go elsewhere for her care.

23. Discussion Points
●What would your first step be?
● How do you help this patient set priorities?
●How can you help her to make realistic decisions?
●How can you advocate on her behalf?

24. Case Study 9
● Stan is a 22 year old man who just graduated from college. Upon
returning from a trip to Europe to celebrate his graduation, he
experienced dizziness and blurring of vision in his right eye. He
thought he was just fatigued so he rested before he started
looking for a job. His symptoms worsened and he began having
balance problems. He saw his primary care physician who referred
him to a neurologist. Following a full examination, MRI, and
lumbar puncture, he was given the diagnosis of MS. The
neurologist suggested that he begin an injectable therapy
immediately to reduce the risk of worsening disease and
subsequent relapses. Stan started searching the Internet and
reviewed all the current research in MS. He found there were
several studies using oral medications. He also reviewed the
efficacy data on currently approved injectables. He then visited the
neurologist and stated that he decided to wait for the oral
medications to reach the market. He was very reluctant to inject
even once a week and would prefer to take a pill to control his
disease.

25. Discussion Points
●What are the major challenges with this patient?
●What is your assessment of this situation?
●What are your first actions?

26. Case Study 10
● Judy is a 36 year old married woman with two children. She
recently had her second child, a healthy baby girl. She is
currently breast feeding and does not want to stop until the
baby is six months old. She is experiencing blurring of vision
in her right eye but does not want steroid treatment
because it would mean that she would have to stop breast
feeding. She was on a injectable medication prior to
becoming pregnant but she is even reluctant to restart since
she states that injecting “tied her down.” She prefers to
wait for the pill. This woman is at high risk post partum for
an MS relapse.

27. Discussion Points
●What are your concerns in this situation?
● What can you do to help her?
●What other help can you enlist?
●What plans are realistic in light of the problems this
patient is facing?

28. Case Study 11
● John is an African American man with a 10 year history of
MS. He has never had a relapse but has experienced slow
progression since his diagnosis. He is self-injecting daily but
feels he is getting worse despite this therapy. He walks with
bilateral supports; he no longer works; he is extremely
depressed; and his wife recently divorced him. He wishes to
stop therapy, start dalfampridine, and be placed on the list
for an oral disease modifying therapy.

29. Discussion Points
● Should we support his decision to stop
his injectable therapy?
●Would an oral disease modifying therapy
be appropriate for him?
●Would dalfapridine help his symptoms
● What other interventions might help
him?

30. Where do we go
from here?

31. Questions or
Comments ?

32. Thank you for your
attention !!!