MS

Multiple Sclerosis

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

 

Neuromyelitis Optica and Spectrum Disorder:

  • Demyelinating disease due to Ab against aquaporin-4 (on oligodendrocytes)
  • Classically causes optic neuritis and longitudinally extensive transverse myelitis
  • Can be more aggressive than MS and needs steroids but in severe or refractory cases PLEX
  • NMO antibodies and MS workup as above is done