Multiple Sclerosis (MS)

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

Epidemiology
  • MS affects more than 2 million people worldwide
Prognosis
  • Relapsing and remitting symptoms is most common clinical course of MS
Comorbidity
  • 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]
Risk Factors
  • Women between ages 20 to 30
  • Low serum vitamin D levels
  • More common in those living further from equator

MS 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
  • 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