1. A CASE OF MULTIPLE SCLEROSIS :
17 YEARS FOLLOW-UP
Dr. L. K. Malhotra
MBBS, MD, DM (Neurology)
Consultant Neurologist
New Delhi, India
2. BACKGROUND
• Tertiary neurocentre : 0-2 new patients of
MS/ yr
• Majority patients have no insurance cover
• Patient can consult any neurologist
throughout India anytime
A CASE OF MULTIPLE SCLEROSIS : 17 YEARS
FOLLOW-UP
3. A CASE OF MULTIPLE SCLEROSIS : 17 YEARS
FOLLOW-UP
• 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. • 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
A CASE OF MULTIPLE SCLEROSIS : 17 YEARS
FOLLOW-UP
8. • Treatment : I.V. -- M.P. 5 g followed by
oral steroids for 2 weeks
• Clinical and radiological improvement
seen
A CASE OF MULTIPLE SCLEROSIS : 17 YEARS
FOLLOW-UP
14. • Oct 2000 : worsening of ataxia
• MRI brain : Fresh brain stem and supra
tentorial lesions
• Treatment : I.V. M.P. 5 g
• Partial Improvement
A CASE OF MULTIPLE SCLEROSIS : 17 YEARS
FOLLOW-UP
15. • Nov 2000 : started on Avonex
A CASE OF MULTIPLE SCLEROSIS : 17 YEARS
FOLLOW-UP
16. • 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
A CASE OF MULTIPLE SCLEROSIS : 17 YEARS
FOLLOW-UP
20. • 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
A CASE OF MULTIPLE SCLEROSIS : 17 YEARS
FOLLOW-UP
25. • Aug 2003 : dysarthric, gaze evoked
nystagmus, limb and gait ataxia, ankle
clonus, brisk jerks, extensor plantars
• Needed support to walk.
• RRMS SPMS
A CASE OF MULTIPLE SCLEROSIS : 17 YEARS
FOLLOW-UP
26. 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
A CASE OF MULTIPLE SCLEROSIS : 17 YEARS
FOLLOW-UP
27. Treatment options :
• Mitoxantrone
• Cyclophosphamide
• I.V. MethylPrednisolone monthly
• I.V. Immunoglobulins
• G.A.
• Injection Rebif
A CASE OF MULTIPLE SCLEROSIS : 17 YEARS
FOLLOW-UP
28. 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
A CASE OF MULTIPLE SCLEROSIS : 17 YEARS
FOLLOW-UP
29. 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
A CASE OF MULTIPLE SCLEROSIS : 17 YEARS
FOLLOW-UP
30. • No urinary / menstrual problem. Mild
alopecia.
• Injection Rebif 22 microgm thrice a week
since Nov 2004 till now.
• And no relapse since then.
A CASE OF MULTIPLE SCLEROSIS : 17 YEARS
FOLLOW-UP
