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dNP

Multiple SclerosisFor Non Neurologists

Naraporn Prayoonwiwat, M.D.Neurology Division, Department of Medicine

Siriraj Hospital

[email protected] 02 419 7101-2

September 24, 2009; Khonkaen

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Multiple Sclerosis

MS is a rare disease, it is unlikely tobe seen in my general practice.

d NP

Do you think so?

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Diagnosis: optic neuritis

Rx: high dose steroids

Case Presentation

A young woman had dimmed

vision of the left eye for 2 days. Eyedrop tried without improvement.

d NP

Eye:

Vision got worse. Pain on eye

movement was noted.

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Case Presentation

A young woman felt spinning for

a few days, getting worse withmotion. There was no hearing lossor visual blurring.

d NP

Diagnosis: vertigo

Rx: antivertigo drug

ENT:

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Case Presentation

A young woman difficulty in

voiding for 3 days.Urinalysis: WBC 3-5, RBC 5-10, fewbacteria

d NP

Diagnosis: acute urinary retention

Rx: Foley’s catherization, quinolone

Urology:

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Case Presentation

A middle age woman had

nausea and vomiting for 5 days. Shehad very frequent hiccoughs for 1day.

EGD: showed mild gastritis

d NP

Diagnosis: acute gastritis

Rx: intravenous PPI

GI:

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Case Presentation

A middle age woman had gait

difficulty 2-3 weeks. She could notproperly lift her feet above theground. There was some numbness

at the lower legs.

d NP

Diagnosis: lumbar spondylosis

Inx: CT myelogram

Orthopedics:

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Case Presentation

A middle age man experienced

itching at the anterior chest left sidefor 1 week. No rash was noted.

d NP

Diagnosis: dermatitis

Rx: topical steriods

Skin:

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Case Presentation


headache for 1-2 months. She couldnot do her routine work, was slow inresponse. Mild weakness was noted.

d NP

Inx: CT brain with contrast -mass

Diagnosis: brain tumor

Surgery:

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Multiple Sclerosis

The neurological deficits inthese patients were caused by

demyelinating disease of the CNS. All of had MS.

d NP

Do you agree?

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Demyelinating Disease

• What is a demyelinating

disease of the CNS?

• What is the significance of

myelin?

d NP

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• Myelin wraps around thenerve axon and contributes to

the conduction velocity of thenerve.

d NP

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• Oligodendrocytes areresponsible for myelin

production in the CNS; whileSchwann cells are responsiblein the PNS.

d NP

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• Diseases affecting the CNSmyelin cause white matter

lesions in the CNS, whereasdiseases affecting the PNScause demyelinating type of

peripheral neuropathy.

d NP

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Immunopathogenesis

Myelinated neuron

Demyelinated neuron

Autoimmune attack

Degenerated neuron

Information flow

Partial Information flow

No Information flow

Disabilities Neurological symptoms

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Demyelinated fiber

Node of Ranvier

axon

Myelinated fiber

Nerve Conductions

d NP

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• What is MS?

d NP

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Multiple Sclerosis

An immune-mediated disorderinvolving mainly the white matter

(myelin) of the CNS which affectssusceptible individuals of both sexesafter exposure to certain

environmental factors.

d NP

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Multiple Sclerosis

- Immune-mediated disorderof the CNS

- White matter (myelin)involvement

- Response to environmentalfactors in susceptible persons

- Affect both sexes

d NP

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Multiple Sclerosis

Scope:

Clinical manifestations

Pathology

Pathogenesis

DiagnosisTreatment in MS

d NP

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dNP

Clinical Presentation

Multiple Sclerosis

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Multiple SclerosisClinical Presentation

Cerebrum

Optic nerve

Cerebellum/cerebellar pathway

Brainstem

Spinal cordBladder & Bowel function

Other

d NP

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Cerebrum

Cognitive impairment

: deficits in attention, reasoning,

executive function (early)

dementia (late)Hemiparesis: UMN

Hemisensory loss

NP

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Cerebrum (2)

Affects (mainly depression)

Epilespy (rare)

Focal cortical deficits (rare)

Psychiatric symptoms (rare)

NP

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Optic nerve

Unilateral painful loss of vision

: scotoma

: reduced visual acuity

: impaired color vision: relative afferent pupillary

defect (RAPD)

NP

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Tremor

: postural tremor

: intention tremor

Clumsiness and poor balance: limb in-coordination

: gait ataxia

NP

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Brainstem

Diplopia (double vision)

Internuclear ophthalmoplegia: INO

Nystagmus

Vertigo

d NP

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Brainstem (2)

Dysarthria (slurred speech)

Dysphagia (swallowing difficulty)

Pseudobulbar palsy

d NP

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Spinal cord

Weakness

: upper motor neuron signs

Stiffness

: spasticityPainful spasms

d NP

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Spinal cord (2)

Bladder dysfunction

Erectile dysfunction (impotence)

Constipation

d NP

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Other

Pain

Fatigue

Paroxysmal symptoms

Temperature sensitivityExercise intolerance

d NP

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Multiple SclerosisCommon Presentations

Optic neuritis acute visual loss,

intraorbital pain on eye movement

Acute myelitis limb weakness,

numbness, urinary retention

Brainstem diplopia, INO, facialnumbness, hemiparesis,

hemisensory loss, ataxia

d NP

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Multiple SclerosisFunctional Status System

Cerebrum

Optic nerve


Brainstem

Spinal cordBladder & Bowel function

Other

d NP

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Clinical Course

d NP

Primary-progressive: PPSecondary–progressive: SP

Progressive-relapsing: PR Relapsing-remitting: RR

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Clinical Course

d NP

Clinical threshold

Inflammation

Axonal loss

Brain

volume

Relapses

PR RR

PPSP

PR

RR

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E xpanded D isability S tatus S cale

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Multiple Sclerosis

Scope:


Pathology

Pathogenesis


d NP

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dNP

Pathology

Multiple Sclerosis

MS: Pathology

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MS: Pathology Active Lesion

d NP

Gross Luxol fast blue

Frohman EM, et al NEJM 2006;354:942-55

MRI

MS: Pathology

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d NP Frohman EM, et al NEJM 2006;354:942-55

LFB stain

Perivascular infiltratesMRP14

(Macrophage)

Numerousmacrophage

PLP mRNA in situ hybridization

Toluidine

blue

Electron

Micrograph

Loss of myelin

Demyelination

MS: Pathology

MS Plaque: Acute

MS Patholog

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MS: Pathology

MS Plaque: Chronic


LFB stainNumerousmacrophage

Demyelinated area Chronic gliotic lesion

Toluidine blue

Astrocyte

No Oligodendrocyte

EM

Astrocyte

Demyelinated axon

Macrophage

Remyelinated axon

Microglia nuclei

MS: Pathology

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MS: Pathology

Demyelination-Remyelination


EM

Demyelinated axon

Remyelinated axon

RemyelinationDemyelination

MS: Pathology

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MS: Pathology

Active Lesion

Werkle H and Lassmann H in McAlpine’s MS 4th Ed. 2005

LossofOPC OPCpreserved

Demyelina5on

OPC: oligodendrocyte progenitor cell

MS: Pathology

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MS: Pathology

Active Lesion


Early Completed

Remyelina5on

OPC: oligodendrocyte progenitor cell

MS: Pathology

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MS: Pathology

Active Lesion


R e m y e l i n a 5 o n

D e m

y e l i n a 5 o n

MS: Pathology

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MS: Pathology

Chronic Lesion


R e m y e l i n a 5 o n

D e m

y e l i n a 5 o n

Arrestofremyelina5ngprocess

l

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Template SR

[email protected] March 26, 2009 02 419 7101-2d NP

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Multiple Sclerosis

Scope:


PathologyPathogenesis


d NP

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dNP

Pathogenesis

Multiple Sclerosis

Pathogenesis

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T

Periphery

Demyelination and axon loss

BBB

Transmigration

Activation via APC,Differentiation,

Proliferation

Trigger

Local reactivation

APC

Adhesion/attraction

Release of cytokinesRecruitment of MΦ

Antibodies

B

Mφ Nitric Oxide

IFN-γ

TNF-α

TNF-α Adapted with kind permission from Prof. R. Hohlfeld

Pathogenesis

Autoreactive T-cells

TT

T

T

T

T

T

CNS

T APC

T

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Multiple Sclerosis

Scope:

Pathology

PathogenesisClinical manifestations

Diagnosis Treatment in MS

d NP

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dNP

Diagnosis

Multiple Sclerosis

Multiple Sclerosis

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Multiple SclerosisDiagnosis

Schumacher 1965Poser 1983

McDonald 2001Revised 2005*

d NP

Recommended Diagnostic Criteria for MS:Guidelines from International Panel.McDonald et al. Ann Neurol 2001;50:121-7*Diagnostic Criteria for Multiple Sclerosis:

2005 Revisions to the “McDonald Criteria”.

Polman, et al. Ann Neurol 2005;58:840-6.

Multiple Sclerosis

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Multiple SclerosisDiagnosis

Schumacher 1965Poser 1983

McDonald 2001Revised 2005*

d NP

Recommended Diagnostic Criteria for MS:Guidelines from International Panel.McDonald et al. Ann Neurol 2001;50:121-7*Diagnostic Criteria for Multiple Sclerosis:

2005 Revisions to the “McDonald Criteria”.

Polman, et al. Ann Neurol 2005;58:840-6.

Multiple Sclerosis

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Multiple SclerosisDiagnostic Consideration

• Objective evidence of

dissemination in time and space

d NP

• Clinical evidence:

presence of clinical signs

history of symptoms:

Ann Neurol 2001;50:121-7

insufficient

Multiple Sclerosis

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Multiple SclerosisInvestigations

• Magnetic resonance imaging

• Evoked potentials:

visual auditorysomatosensory motor

• CSF analysis

cell count IgG index

oligoclonal band

d NP

Multiple Sclerosis

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Multiple SclerosisMRI Criteria

MRI criteria:• Dissemination in space

brain MRIspinal cord MRI

• Dissemination in time

Barkhof F. Brain 1997;120:2059-69Tintore M. Am J Neuroradiol 2000;21:702-6 NP

Multiple Sclerosis

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brain MRI spinal cord MRI



Multiple Sclerosis

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Multiple SclerosisDissemination in Space

Brain MRI criteria:• 9 T2 hyperintense lesions or

1 Gd-enhancing lesion• > 1 infratentorial lesion

• > 1 juxtacortical lesion

(subcortical U-fiber)• > 3 periventricular lesions

Barkhof F. Brain 1997;120:2059-69Tintore M. Am J Neuroradiol 2000;21:702-6

Lesion > 3 mm in cross section

3 i n 4

Spinal cord

d NP

MRI Criteria for

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T2W lesions > 9

MRI Criteria for Dissemination in Space

or

Gd+ lesion

3 in 4 1)

2) 3) 4)

>1 Infra-tentorial

>1 Juxta-cortical

> 3 peri-ventricular

> 1


MRI Criteria for

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MRI Criteria forDissemination in Space

or

Gd+ lesion

3 in 4

T2W lesion

1)

2) 3) 4)

>1 Infra-tentorial

>1 Juxta-cortical


> 1 > 9


Nine or more hyperintense

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Nine or more hyperintense

lesions in T2 (or FLAIR)

FLAIR T2Wd NP Ann Neurol 2001;50:121-7

One Gd enhancing lesion

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One Gd enhancing lesionin T1

T1W T1W c Gdd NP Ann Neurol 2001;50:121-7

At least one

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At least one infratentorial lesion

d NP Ann Neurol 2001;50:121-7

At least one

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At least one juxtacortical lesion

FLAIR d NP Ann Neurol 2001;50:121-7

At least three

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At least three periventricular lesions

FLAIR d NP Ann Neurol 2001;50:121-7

Multiple Sclerosis

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Multiple Sclerosis

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Spinal MRI criteria:• Little or no swelling of cord• T2 hyperintense lesions

- size > 3 mm- length < 2 vertebral segments- partial involvement of cord

(cross section)


MRI Criteria for

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MRI Criteria for Dissemination in Space

or

3 in 4

2)

>1 Infra-tentorial

3)

>1 Juxta-cortical

4)


Gd+ lesion

1)

> 1 T2W lesions > 9 =

Note


Little or no cord swelling

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Little or no cord swelling

d NP

T1W w GdT2W

Ann Neurol 2001;50:121-7

T2W lesion > 3 mm

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T2W lesion > 3 mm


T2W

Cervical cord

T2W T2W

Cervical cord

Length <2 vertebral

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Length <2 vertebralbody segments


T1W w GdT2W

Partial involvement of cord

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Partial involvement of cord


T2W T2W

Cervical cord

Multiple Sclerosis

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Spinal MRI criteria (revised):• A spinal lesion is equivalent to

a brain infratentorial lesion• An enhancing spinal lesion equals

to an enhancing brain lesion• Individual spinal lesions count

together with individual brain

lesions


MRI Criteria for

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MRI Criteria for Dissemination in Space (spinal)

1)

3)

2)

count each spinaltogether with eachbrain lesion

Gd +lesion

1 = =

Infra-tentoriallesion

1

Ann Neurol 2005;58:840-6

+ =

d NP

Brainstem and spinal lesion

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d NP

T2W

One spinal lesion can besubstituted for one

infratentorium brain

lesion.

A n n

N e u r o l

2 0 0 5 ; 5 8 : 8 4 0 - 6

Brainstem and spinal lesion

Spinal Gd-enhanced lesion

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d NP

T1W w Gd T2WT2W

Cervical cordOne spinal Gd lesion can

be substituted for oneGd brain lesion.

Ann Neurol 2005;58:840-6

Spinal Gd enhanced lesion

Multiple Sclerosis

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Multiple Sclerosis

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Multiple SclerosisDissemination in Time

a. 1st scan >3 mo of clinical onset:

d NP

• Gd positive lesions; not at the site

implicated in the original clinicalevent

Follow-up scan ~ 3 mo

• New T2 lesion• New Gd positive lesion

2001

Ann Neurol 2001;50:121-7

Multiple Sclerosis

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Multiple SclerosisDissemination in Time

b. 1st scan <3 mo of clinical onset:

d NP

2001

Ann Neurol 2001;50:121-7

• No Gd positive lesion

Follow-up scan > 3 mo of onset• New Gd positive lesion If not

Follow-up scan > 3 mo of 1st scan

• New T2 lesion• New Gd positive lesion

MRI Criteria for

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Dissemination in Time Clinical

event

Category 1 yes

yes

yesGd +veNew T2

3 months3 months

Ann Neurol 2001;50:121-7

2001

d NP

Multiple Sclerosis

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p oDissemination in Time

a. 1st scan >3 mo of clinical onset:

d NP

• Gd positive lesions; not at the siteimplicated in the original clinicalevent

b. 1st scan >1 mo of clinical onset;

Follow-up any time after 1st scan• New T2 lesion

Polman et al. Ann Neurol 2005;58:840-6

Revised2005

MRI Criteria for

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Dissemination in Time Clinical

event

Category 2

yes yes

yesGd +veNew T2

3 months

3 months

Ann Neurol 2001;50:121-7

2001

MRI Criteria for

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Dissemination in Time clinicalevent 3 months 3 months

3 months

Category 1

Category 2

yes yes

yes

yes yes yes

Gd +veNew T2

Ann Neurol 2001;50:121-7

2001

d NP

MRI Criteria for

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Dissemination in Time clinicalevent 3 months

1 monthCategory 1

Category 2

yes

yes

Gd +ve

New T2

Any timePolman et al. Ann Neurol 2005;58:840-6

Revised2005

d NP

Multiple Sclerosis

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pInvestigation




• CSF analysis


oligoclonal band

d NP

Multiple Sclerosis

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pInvestigation

d NP Visual Evoked Potentials

Multiple Sclerosis

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pInvestigations




• CSF analysis


oligoclonal band

d NP

Multiple Sclerosis

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pInvestigation

d NP CSF oligoclonal bands

Serum

CSF

Serum: +CSF : ++

Serum: -

CSF : ++

Multiple SclerosisDi i C i i Revised

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dNP

Diagnostic Criteria

Primary Progressive Multiple SclerosisClinical Data Additional Data

Brain MRI positive1 year of diseaseprogression

(prospective- retrospective)

9 T2 lesions

Spinal MRI positive

> 4 T2 lesions + VEP

2 focal T2 lesionsCSF positive

Ann Neurol 2005;58:840-6

OCB or IgG indexPlus 2/3 of

Revised2005

Criteria: Primary Progressive MS

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dNP

y g

Progressive course 1 y

T2W

9 2 >4 Ann Neurol 2005;58:840-6

Revised2005

Brain Spinal CSF

- Oligoclonal

bands

- IgG index

Plus 2/3 of

or + VEP

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dNP

Differential Diagnosis

Multiple Sclerosis

Multiple Sclerosis

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pDifferential Diagnosis

ADEM APL syndrome

SLE CNS vasculitis

Behcet’s disease 1o Sjogren syndrome

CADASIL Sarcoidosis

CNS infection: HIV, PML, SSPE, Lyme’s disease,

meningovascular syphilis, Whipple’s disease

Mitochondrial 1o CNS lymphomaencephalopathy

d NP

ADEM: acute demyelinating encephalomyelitis, APL: antiphospholipid, SLE: systemic lupuserythematosus, CNS: central nervous system, CADASIL: cerebral autosomal dominant arteriopathy

with subcortical infarcts and leucoencephalopathy, HIV: human immune deficiency virus, PML:

progressive multifocal leucoencephalopathy, SSPE: subacute sclerosing panencephalitis

Multiple Sclerosis

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pDifferential Diagnosis

Tabes dorsalis

Familial ataxia

Subacute combined degeneration

(B12 deficiency)

Spinal cord tumor

Cervical spondylosis

d NP

Neuromyelitis Optica

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Diagnosis

Absolute criteria: Optic neuritis + acute myelitisNo clinical disease outside optic-spinalSupportive criteria:

Major: negative brain MRI at onsetabnormal spinal cord MRI > 3 vertebraCSF > 50 WBC/mm3 or > 5 PMN/mm3

Minor:

bilateral optic neuritissevere ON, VA < 20/200 in 1 or 2 eyesevere fixed weakness (MRC < 2 in 1 or morelimbs

d NP Wingerchuck et al. Neurology 1999;53:1107-14.


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Diagnosis

Absolute criteria: Optic neuritis + acute myelitisNo clinical disease outside optic-spinalSupportive criteria:

Major: negative brain MRI at onsetabnormal spinal cord MRI > 3 vertebraCSF > 50 WBC/mm3 or > 5 PMN/mm3

Minor:

bilateral optic neuritissevere ON, VA < 20/200 in 1 or 2 eyesevere fixed weakness (MRC < 2 in 1 or morelimbs

d NP

Absolute criteria: Optic neuritis + acute myelitisNo clinical disease outside

optic-spinal

Supportive criteria: Major: negative brain MRI at onsetabnormal spinal MRI > 3 vertebra

CSF >50 WBC or >5 PMN per mm3

Supportive criteria: Minor: bilateral optic neuritis

severe ON, VA< 20/200 in 1 or 2 eyesevere fixed weakness (MRC < 2

in 1 or more limbs

Wingerchuck et al. Neurology 1999;53:1107-14.


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Diagnosis

Definite NMO:

Optic neuritis

acute myelitis

Supportive criteria: 2 in 3Brain MRI not compatible with Barkhof’s criteria

Spinal MRI > 3 vertebral body segments

NMO IgG antibody positive

d NP Wingerchuck et al. Neurology 2006;66:1485-9.

Definite NMO: • Optic neuritis• acute myelitis

Supportive criteria: 2 in 3• Brain MRI not compatible with

Barkhof’s criteria

• Spinal MRI > 3 vertebral bodysegments

• NMO IgG antibody positive

Multiple Sclerosis

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Multiple Sclerosis

Scope:



Diagnosis

Treatment

d NP

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dNP

Treatment

Multiple Sclerosis

Multiple Sclerosis

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Treatment

Acute relapses

Disease modifying therapies (DMT)

Symptom control

d NP

Multiple Sclerosis

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Treatment

Acute relapses


Symptom control

d NP

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Multiple Sclerosis

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Acute Relapses Rx

2. Plasma exchange

Rational: To remove circulating

autoantibodies, complimentsIndication: Severe steroid-resistant

relapses, neuromyelitis optica (NMO),

acute disseminated encephalomyelitis(ADEM) within 1 month of onset of

symptom

d NP Kieseier BC, et al. Curr Opion Neurol 2007;20:286-93

Multiple Sclerosis

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Acute Relapses Rx

2. Plasma exchange

Rx: 1 plasma volume

7 exchanges alternate day

d NP Kieseier BC, et al. Curr Opion Neurol 2007;20:286-93

Multiple Sclerosis

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Treatment

Acute relapses


Symptom control

d NP

Multiple Sclerosis

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Disease Modifying Therapy

Disease modifying therapies DMT

1. Interferon beta

2. Glatiramer acetate

3. Mitoxantrone

4. Monoclonal antibodies

5. Oral therapies

De Angelis T, Lublin F. Curr Opion Neurol 2007;20:261-71

Costello FC, Stuve O, Weber M, et al. Curr Opion Neurol 2007;20:281-5

Kieseier BC, Weindl H, Hemmer B, et al. Curr Opion Neurol 2007;20:286-93dNP

Multiple Sclerosis

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1. Interferon beta IFN β

Mechanism: Anti-inflammatory effect by

- inhibit cytokine production- limit access of immune cell infiltration

to CNS




Multiple Sclerosis

f

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IM: intramuscular, Sc: subcutaneous, wk: week, AD: alternate day

Type Drug Company µg Route Dose

IFN β 1a AvonexR Biogen Idec 30 IM 1/wk Rebif R Merck Serono 22, 44 Sc 3/wk

IFN β 1b BetaseronR Bayer Schering

Pharma

250 Sc AD

1. IFN β 1

Multiple Sclerosis

i dif i h

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2. Glatiramer acetate (Copolymer-1)

Mechanism: Anti-inflammatory effect by

- induce changes in phenotypicexpression of T helper cell

- modify central effects of inflammation




Multiple Sclerosis

Di M dif i Th

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3. Mitoxantrone

Mechanism:

- reduce Th1 cytokines- eliminate lymphocytes

Indication: SP MS, PR MS,

refractory RR MS




Multiple Sclerosis

Di M dif i Th

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Mechanism: Targeted therapies of

molecules involved in pathogenesis




Multiple Sclerosis

DMT M l l A tib d

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DMT: Monoclonal Antibody

dNP

Type Drug Company Target

Natalizumab TysabriR Biogen Idec α-4 integrins

Alemtuzumab CampathR Bayer Schering

Pharma

CD52 NK, B cell

Rituximab MabTheraR Roche CD20 B cell

Daclizumab ZenapaxR Biogen Idec CD25, IL 2



Kieseier BC, Weindl H, Hemmer B, et al. Curr Opion Neurol 2007;20:286-93

Multiple Sclerosis

Di M dif i Th

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Disease modifying therapies DMT

1. Interferon beta

2. Glatiramer acetate

3. Mitoxantrone


5. Oral therapies




Multiple Sclerosis

O l Th

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Oral Therapy

5.1 Cladribine (Merck Serono)

5.2 Fingolimod (Novartis)

5.3 Fumaric acid ester (Biogen Idec)

5.4 Laquinimod (Teva Neurosci.)

5.5 Teriflunamide (Sanofi Aventis)

5.6 Glatiramer acetate (Teva Neurosci.)5.7 statin




Multiple SclerosisT t t

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Treatment

Acute relapses


Symptom control

d NP

Multiple SclerosisS t C t l

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Symptom Control

Weakness

Spasticity

PainFatigue

Psychological disorders

d NP


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Symptom Control

Weakness

Rehabilitation:

increase strengthincrease endurance

d NP


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Symptom Control

Spasticity

Exercise

MassageCentral muscle relaxant:

baclofen, tizanidine

Botulinum toxin injection

d NP


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Symptom Control

Pain

neuropathic pain

- antidepressant: TCAs, SSRIs- anticonvulsant: carbamazepine,

gabapentin, oxcarbazepine,

pregabalin

NP

Multiple SclerosisS mptom Cont ol

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Symptom Control

Pain

tonic spasm: spontaneous, action

- behavior adjustment: slow, steadymovement

- antidepressant: TCAs, SSRIs

- central muscle relaxant:

baclofen, tizanidine

NP

Multiple SclerosisSymptom Control

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Symptom Control

Fatigue: feeling lack of ‘energy’

- not weakness or depressive mood

- improve with exercise- balance between rest and exercise

- keep cool while exercise

d NP

Multiple SclerosisSymptom Control

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Symptom Control

Psychological disorders:

Depressive mood

- psychological support- antidepressant: TCAs, SSRI

Anxiety

- psychological support

- anxiolytic

NP

Multiple SclerosisTreatment

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Treatment

Acute relapses


Symptom control

d NP

Multiple Sclerosis

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p

Scope:



Diagnosis

Treatment in MS

d NP

Case Presentation

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Diagnosis: optic neuritisRx: high dose steroids

A young woman had dimmed

vision of the left eye for 2 days. Eyedrop tried without improvement.

d NP

Eye:

Vision got worse. Pain on eye

movement was noted.

Case Presentation

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A young woman felt spinning for

a few days, getting worse withmotion. There was no hearing lossor visual blurring.

d NP

ENT:

Few days later she had double

vision, nystagmus and ataxia.MRI: brainstem lesion

Diagnosis: clinically isolated synd.Rx: high dose steroids

Case Presentation

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A young woman difficulty in

voiding for 3 days.Urinalysis: WBC 3-5, RBC 5-10, fewbacteria

d NP

Urology:

One day later she developed

numbness and weakness of bothlegs.

LP: h WBC

MRI: intrinsic cord lesion T level

Diagnosis: acute myelitis

Case Presentation

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A young woman had nausea and

vomiting for 5 days. He had veryfrequent hiccoughs for 1 day.

EGD: showed mild gastritis

d NP

Rx: iv methylprednisolone (MP)

GI:

Past history: visual loss (optic

neuritis) left eye

Case Presentation

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A middle age woman had gait

difficulty 2-3 weeks. She could notproperly lift her feet above theground. There was some numbness

at the lower legs.

d NP

Diagnosis: lumbar spondylosisCT myelogram: disc herniation

Orthopedics:

Rx: laminectomy

Few months later she had bilateralvisual loss.

Dx: RR MS

Case Presentation

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A middle age man experienced

itching at the anterior chest left sidefor 1 week. No rash was noted.

d NP

Diagnosis: dermatitisRx: topical steriods

Skin:

Few weeks later he had numbness

at the left chest down to the leftleg and weakness of both legs.

MRI: intrinsic cord lesionRx: IV MP

Case Presentation

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headache for 1-2 months. She couldnot do her routine work, was slow inresponse. Mild weakness was noted.

d NP

Inx: CT brain with contrast -massDiagnosis: brain tumor

Surgery:

Brain biopsy: chronic demyelination

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dNP

MS

Q&A

Acute Optic NeuritisInvestigations

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Investigations

1. Demonstrate the lesion

2. Look for other site involved

3. Look for other causes

d NP

Optic nerve MRI, VEPs Brain, whole cord MRI,

CSF oligoclonal bands Immune profile, (anti HIV)

Acute MyelitisInvestigations

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Investigations

1. Demonstrate the lesion

2. Look for other site involved

3. Look for other causes

Whole cord MRI

Brain MRI, VEPs, CSF

oligoclonal bands

MS-KKU 24-09-2009

Documents