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cl:multiple-sclerosis [on September 16, 2018]
cl:multiple-sclerosis [on December 29, 2021] (current)
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 +====== Multiple Sclerosis (MS) ======
 +{{INLINETOC}}
 +===== Primer =====
 +**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.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC1739575/​|Siegert,​ R. J., & Abernethy, D. A. (2005). Depression in multiple sclerosis: a review. Journal of Neurology, Neurosurgery & Psychiatry, 76(4), 469-475.]])]
 +    * 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.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2706287/​|Chwastiak,​ L. A., & Ehde, D. M. (2007). Psychiatric issues in multiple sclerosis. Psychiatric Clinics of North America, 30(4), 803-817.]])]
 +  * There is an increased risk for suicide.[([[https://​pubmed.ncbi.nlm.nih.gov/​28327056/​|Feinstein,​ A., & Pavisian, B. (2017). Multiple sclerosis and suicide. Multiple Sclerosis Journal, 23(7), 923-927.]])]
 +
 +== Risk Factors ==
 +  * Women between ages 20 to 30
 +  * Low serum vitamin D levels
 +  * More common in those living further from equator
 +
 +===== Diagnosis =====
 +==== Signs and Symptoms ====
 +MS can present with non-specific signs and symptoms including:
 +  * Acute optic neuritis
 +    * Painful unilateral visual loss assoiated with relative afferent pupillary defect (RAPD)
 +  * [[neurology:​neuro-exam:​home|Abnormal neurological exam]], including brain stem/​cerebellar syndromes (e.g. - diplopia, ataxia, [[neurology:​approach-aphasia|ataxic dysarthria (scanning speech)]], [[neurology:​approach-tremors|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
 +
 +==== Neuropsychiatric ====
 +  * Rare cases of psychosis as an initial symptom of MS has been reported.[([[https://​pubmed.ncbi.nlm.nih.gov/​34927555/​|Özbudak,​ P., Erçelebi, H., & Gücüyener,​ K. (2021). Psychosis: a rare onset symptom of pediatric multiple sclerosis. Neurocase, 1-3.]])]
 +===== Pathophysiology =====
 +  * MS is thought to occur due to autoimmune inflammation and demyelination of CNS (brain and spinal cord) with subsequent axonal damage.
 +
 +===== Investigations =====
 +==== CSF ====
 +  * Increased IgG level and myelin basic protein in CSF. Oligoclonal bands are diagnostic. ​
 +
 +==== Neuroimaging ====
 +  * 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
 +
 +===== Treatment =====
 +  * 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
 +
 +===== Resources =====
 +  * [[https://​www.nejm.org/​doi/​full/​10.1056/​NEJMra1401483|Review Article - Longo, D. L. (2018). Multiple Sclerosis. N Engl J Med, 378, 169-80.]]