MS

Background

• Progressive inflammatory disorder primarily manifesting with demyelination of the central white matter
• Optic neuritis and transverse myelitis (spinal cord lesion) are common presentations
• Generally develop over a few days; very uncommon to happen suddenly ( e.g., patients will complain about a dark spot appearing in their vision that expands over several days)

Evaluation

• MRI w/ and w/o contrast can identify plaques and determine if they are more acute
  • “Active” MS plaque will enhance, and continues to for weeks (even after treatment)
• Modified MacDonald Criteria: ≥3 characteristic demyelinating lesions (>1 cm, periventricular, infratentorial (brainstem/cerebellum/cord) or juxtacortical in location) with evidence of separation in time (active and chronic)
• LP can be done to look for oligoclonal bands, IgG index, cell count and protein

Management

• Treat flares with steroids: speeds up recovery but does not improve the degree of recovery
  • Would confirm with Neurology (as primary or consulting team) preferred dose, which is often methylpred 1g to start
  • Current guidelines are for optic neuritis to be treated with IV steroids, but recent data challenges this
• If a patient with known MS has worsening symptoms that are not new, then recrudescence is the likely cause -> infectious/toxic/metabolic workup and imaging is needed
• Several long-term medications, with common side effects listed below:
  • Interferon (SQ injections) – flu-like symptoms, injection site reactions
  • Glatiramer acetate (SQ) – injection site reactions
  • Fingolimod (PO) – macular edema, liver injury, increased risk of skin cancer
  • Teriflunomide (PO) – liver injury, hair loss, immunosuppression, teratogenic
  • Dimethyl fumarate (PO) – GI side effects, lymphocytopenia, liver injury
  • Natalizumab (IV) – PML concern, immunosuppression
  • Ocrelizumab (IV) – contraindicated in active HBV infection, cannot give live vaccines
  • Alemtuzumab (IV) – autoimmune disease, rash, headache