Multiple Sclerosis (MS)

Multiple Sclerosis (MS) is a chronic inflammatory disease of the central nervous system, and associated with neuropsychiatric symptoms including depression.

• MS affects more than 2 million people worldwide

• Relapsing and remitting symptoms is most common clinical course of MS

• Individuals with MS have a 50% lifetime risk for depression.^[1]
  • Depression in MS patients not like typical depression - there is usually less neurovegetative symptoms. If there is a family history of depression, there is an 80% chance of developing depression in MS. Fatigue is also a common symptom.^[2]
• There is an increased risk for suicide.^[3]

• Women between ages 20 to 30
• Low serum vitamin D levels
• More common in those living further from equator

MS can present with non-specific signs and symptoms including:

• Acute optic neuritis
  • Painful unilateral visual loss assoiated with relative afferent pupillary defect (RAPD)
• Abnormal neurological exam, including brain stem/cerebellar syndromes (e.g. - diplopia, ataxia, ataxic dysarthria (scanning speech), intention tremor, nystagmus/INO [bilateral > unilateral])
• Pyramidal tract demyelination, causing weakness and spasticity
• Spinal cord syndromes
  • Electric shock-like sensations along cervical spine on neck flexion
  • Neurogenic bladder
  • Paraparesis
  • Sensory changes affecting the trunk or one or more of the upper and/or lower extremity
• Symptoms may be exacerbated with increased body temperature such as when the individual takes a hot bath or exercises

• Rare cases of psychosis as an initial symptom of MS has been reported.^[4]

• MS is thought to occur due to autoimmune inflammation and demyelination of CNS (brain and spinal cord) with subsequent axonal damage.

• Increased IgG level and myelin basic protein in CSF. Oligoclonal bands are diagnostic.

• Neuroimaging with MRI is gold standard approach to diagnosis
  • Periventricular plaques (areas of oligodendrocyte loss and reactive gliosis) can be seen on neuroimaging along with multiple white matter lesions

• Disease-modifying therapies can stop relapses and halt or slow progression:
  • β-interferon
  • Glatiramer
  • Natalizumab)
• Acute flares are treated with IV steroids
• Symptomatic treatment for other issues include catheterization, and muscarinic antagonists for for neurogenic bladder
  • Baclofen, GABAB receptor agonists can be used for spasticity
  • Tricyclic antidepressants, and anticonvulsants can be used for pain

• Review Article - Longo, D. L. (2018). Multiple Sclerosis. N Engl J Med, 378, 169-80.