Multiple Sclerosis (MS)

Unilateral or asymmetric optic neuritis and bilateral internuclear ophthalmoplegia are typical.

Central vision is affected more than peripheral vision.

Optic neuritis Optic Neuritis Optic neuritis is inflammation of the optic nerve. Symptoms are usually unilateral, with eye pain and partial or complete vision loss. Diagnosis is primarily clinical. Treatment is directed... read more causes loss of vision (ranging from scotomas to blindness), eye pain during eye movement, and sometimes abnormal visual fields, a swollen optic disk, or a partial or complete afferent pupillary defect.

Internuclear ophthalmoplegia Internuclear Ophthalmoplegia Internuclear ophthalmoplegia is characterized by paresis of ipsilateral eye adduction in horizontal gaze but not in convergence. It can be unilateral or bilateral. (See also Overview of Neuro-ophthalmologic... read more results if there is a lesion in the medial longitudinal fasciculus connecting the 3rd, 4th, and 6th nerve nuclei. During horizontal gaze, adduction of one eye is decreased, with nystagmus of the other (abducting) eye; convergence is intact. In MS, internuclear ophthalmoplegia is typically bilateral; unilateral internuclear ophthalmoplegia is often caused by ischemic stroke.

Rapid, small-amplitude eye oscillations in straight-ahead (primary) gaze (pendular nystagmus) are uncommon but characteristic of MS. Vertigo is common. Intermittent unilateral facial numbness or pain (resembling trigeminal neuralgia Trigeminal Neuralgia Trigeminal neuralgia is severe paroxysmal, lancinating facial pain due to a disorder of the 5th cranial nerve. Diagnosis is clinical. Treatment is usually with carbamazepine or gabapentin; sometimes... read more ), palsy, or spasm may occur. Mild dysarthria may occur, caused by bulbar weakness, cerebellar damage, or disturbance of cortical control. Other cranial nerve deficits are unusual but may occur secondary to brain stem injury.

Weakness is common. It usually reflects corticospinal tract damage in the spinal cord, affects the lower extremities preferentially, and is bilateral and spastic.

Deep tendon reflexes Deep tendon reflexes (See also Introduction to the Neurologic Examination) Deep tendon (muscle stretch) reflex testing evaluates afferent nerves, synaptic connections within the spinal cord, motor nerves, and descending... read more (eg, knee and ankle jerks) are usually increased, and an extensor plantar response (Babinski sign Pathologic reflexes ) and clonus Other reflexes are often present. Spastic paraparesis produces a stiff, imbalanced gait; in advanced cases, it may confine patients to a wheelchair. Painful flexor spasms in response to sensory stimuli (eg, bedclothes) may occur late. Cerebral or cervical spinal cord lesions may result in hemiparesis, which sometimes is the presenting symptom.

Reduced mobility increases the risk of osteoporosis.

In advanced MS, cerebellar ataxia plus spasticity may be severely disabling; other cerebellar manifestations include slurred speech, scanning speech (slow enunciation with a tendency to hesitate at the beginning of a word or syllable), and Charcot triad (intention tremor, scanning speech, and nystagmus).

Paresthesias and partial loss of any type of sensation are common and often localized (eg, to one or both hands or legs).

Various painful sensory disturbances (eg, burning or electric shocklike pains) can occur spontaneously or in response to touch, especially if the spinal cord is affected. An example is Lhermitte sign, an electric shocklike pain that radiates down the spine or into the legs or arms when the neck is flexed.

Objective sensory changes tend to be transient and difficult to demonstrate early in the disease.

Involvement commonly causes bladder dysfunction (eg, urinary urgency or hesitancy, partial retention of urine, mild urinary incontinence). Constipation, erectile dysfunction in men, and genital anesthesia in women may occur. Frank urinary and fecal incontinence may occur in advanced MS.

Spinal cord lesions (plaques) are a common source of neuropathic pain.

Progressive myelopathy, a variant of MS, causes spinal cord motor weakness but no other deficits.

If MRI plus clinical findings are not diagnostic, additional testing may be necessary to objectively demonstrate separate neurologic abnormalities. Such testing may include evoked potentials and, occasionally, CSF examination or blood tests.

Evoked potentials Measurement of Evoked Responses (Potentials) Visual, auditory, or tactile stimuli are used to activate corresponding areas of the cerebral cortex, resulting in focal cortical electrical activity. Ordinarily, these small potentials are... read more (delays in electrical responses to sensory stimulation) are often more sensitive for MS than symptoms or signs. Visual evoked responses are sensitive and particularly helpful in patients with no confirmed cranial lesions (eg, those with lesions only in the spinal cord). Somatosensory evoked potentials and brain stem auditory evoked potentials are sometimes also measured.

CSF examination is being done less frequently (because the diagnosis can usually be based on MRI) but can be helpful if MRI plus clinical findings are inconclusive or if infection (eg, CNS Lyme disease Lyme Disease Lyme disease is a tick-transmitted infection caused by the spirochete Borrelia species. Early symptoms include an erythema migrans rash, which may be followed weeks to months later by... read more ) must be ruled out. CSF tests include opening pressure, cell count and differential, protein, glucose, IgG, oligoclonal bands, and usually myelin basic protein and albumin. IgG is usually increased as a percentage of CSF components, such as protein (normally < 11%) or CSF albumin (normally < 27%). IgG levels correlate with disease severity. Oligoclonal IgG bands can usually be detected by electrophoresis of CSF. Myelin basic protein may be elevated during active demyelination. CSF lymphocyte count and protein content may be slightly increased.

Blood tests may be necessary. Sometimes systemic disorders (eg, SLE Systemic Lupus Erythematosus (SLE) Systemic lupus erythematosus is a chronic, multisystem, inflammatory disorder of autoimmune etiology, occurring predominantly in young women. Common manifestations may include arthralgias and... read more ) and infections (eg, Lyme disease Lyme Disease Lyme disease is a tick-transmitted infection caused by the spirochete Borrelia species. Early symptoms include an erythema migrans rash, which may be followed weeks to months later by... read more ) can mimic MS and should be excluded with specific blood tests. Blood tests to measure an IgG antibody specific for neuromyelitis optica spectrum disorder Neuromyelitis Optica Spectrum Disorder (NMOSD) Neuromyelitis optica spectrum disorder is a demyelinating disorder that predominantly affects the eyes and spinal cord but can affect other structures in the central nervous system (CNS) that... read more (aquaporin-4 antibody [also known as NMO-IgG] and anti-MOG [myelin oligodendrocyte glycoprotein] antibodies) may be done to differentiate that disorder from MS.

Corticosteroids, given in brief courses, are used to treat acute onset of symptoms or exacerbations that cause objective deficits sufficient to impair function (eg, loss of vision, strength, or coordination); regimens include

Some data show that high-dose methylprednisolone (1000 mg/day for 3 consecutive days) orally or IV may have similar efficacy (1 Treatment references Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more , 2 Treatment references Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more ). Some evidence indicates that IV corticosteroids shorten acute exacerbations, slow progression, and improve MRI measures of disease.

If corticosteroids are ineffective in reducing the severity of an exacerbation, plasma exchange Plasma exchange Apheresis refers to the process of separating the cellular and soluble components of blood using a machine. Apheresis is often done on donors where whole blood is centrifuged to obtain individual... read more may be used. Plasma exchange can be used for any relapsing form of MS (relapsing-remitting, progressive relapsing, secondary progressive). It is not used for primary progressive MS.

Plasma exchange and hematopoietic stem cell transplantation Hematopoietic Stem Cell Transplantation Hematopoietic stem cell (HSC) transplantation is a rapidly evolving technique that offers a potential cure for hematologic cancers ( leukemias, lymphomas, myeloma) and other hematologic disorders... read more may be somewhat useful for severe, intractable disease.

For additional information, see Practice guideline recommendations summary: Disease-modifying therapies for adults with multiple sclerosis.

Immunomodulatory therapy, such as interferons or glatiramer, decreases the frequency of acute exacerbations and delays eventual disability. Typical regimens include the following:

Common adverse effects of interferons include flu-like symptoms and depression (which tend to decrease over time), development of neutralizing antibodies after months of therapy, and cytopenias.

Glatiramer acetate may be used.

The following oral immunomodulatory medications can be used to treat relapsing forms of MS, including active secondary MS.

These oral immunomodulatory medications are probably more effective in some patients than glatiramer and the interferons (3 Treatment references Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more , 4 Treatment references Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more , 5 Treatment references Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more ).

Because most people are averse to self-injection, oral immunomodulatory medications are being increasingly used as first-line treatments for relapsing forms of MS.

Disease-modifying therapies can be used to treat relapsing forms of MS. There is no consensus regarding choice of disease-modifying immunomodulatory therapy. Many experts recommend patient education and shared decision-making, including when disease-modifying therapies are offered to patients who have > 1 lesion (seen on imaging) and a clinically isolated syndrome. If one medication is ineffective, a different one can be tried.

The immunosuppressant mitoxantrone may be helpful, particularly for progressive MS that is refractory to other treatments. However, mitoxantrone has been used less since the advent of monoclonal antibodies to treat MS.

Natalizumab, an anti–alpha-4 integrin antibody, inhibits passage of leukocytes across the blood-brain barrier; given as a monthly infusion, it reduces number of exacerbations and new brain lesions but may increase the risk of progressive multifocal leukoencephalopathy Progressive Multifocal Leukoencephalopathy (PML) Progressive multifocal leukoencephalopathy (PML) is caused by reactivation of the JC virus. The disease usually occurs in patients with impaired cell-mediated immunity, particularly patients... read more (PML).

Medications that increase the risk of PML include the following (in descending order of risk):

If any of these medications are used, consultation with a neurologist with training in MS is highly recommended. Before these medications are started, blood tests should be done to check for antibodies to JC virus (JCV), which causes PML. Based on the results, the following is done:

If the high-risk medication is continued, MRI of the brain should be done about every 6 months.

Development of PML symptoms (eg, aphasia, change in mental status, hemianopia, ataxia) requires immediate brain MRI, with and without gadolinium. MRI can often distinguish PML from MS. After MRI, a lumbar puncture Lumbar Puncture (Spinal Tap) Lumbar puncture is used to do the following: Evaluate intracranial pressure and cerebrospinal fluid (CSF) composition (see table Cerebrospinal Fluid Abnormalities in Various Disorders) Therapeutically... read more should be done, and cerebrospinal fluid should be tested for JCV DNA by polymerase chain reaction (PCR). A positive result indicates PML, and emergency consultation with a neurologist and an infectious disease specialist is needed. Also, if patients with a positive result have taken natalizumab, plasma exchange Plasma exchange Apheresis refers to the process of separating the cellular and soluble components of blood using a machine. Apheresis is often done on donors where whole blood is centrifuged to obtain individual... read more can be done to remove the medication quickly, and if immune reconstitution inflammatory syndrome Immune reconstitution inflammatory syndrome (IRIS) Human immunodeficiency virus (HIV) infection results from 1 of 2 similar retroviruses (HIV-1 and HIV-2) that destroy CD4+ lymphocytes and impair cell-mediated immunity, increasing risk of certain... read more (IRIS) develops, corticosteroids are given.

Alemtuzumab, an anti-CD52 humanized monoclonal antibody given IV, has been shown to be effective in the treatment of MS. However, because it increases risk of autoimmune disorders, serious infusion reactions, and certain cancers, alemtuzumab is usually used only when treatment with ≥ 2 other medications has been ineffective.

Cladribine is effective in relapsing forms of MS and may be an appropriate treatment for relapsing MS that is highly active. Cladribine is given orally in two yearly treatment courses. Lymphocyte counts should be monitored before, during, and after treatment, and patients should be closely monitored for adverse effects related to immunosupression.

Ocrelizumab, an anti-CD20 (B-cell) humanized monoclonal antibody given as an infusion every 6 months, is also effective in the treatment of relapsing MS (6 Treatment references Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more ). Ocrelizumab can also be used to treat primary progressive MS, typically in ambulatory patients.

Ofatumumab, also an anti-CD20 (B-cell) humanized monoclonal antibody, is used to treat relapsing forms of MS, including clinically isolated syndrome. and active secondary progressive disease. It is given by subcutaneous injection (self-administered [ 7 Treatment references Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more ]).

Ublituximab, a chimeric monoclonal antibody is also used to treat relapsing forms of MS, including clinically isolated syndrome, and active secondary progressive disease. It is given as an IV infusion.

Rituximab (off label for MS in the United States) is also more effective than glatiramer and the interferons (8 Treatment references Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more ); it is commonly used throughout Europe and Canada because it is much less expensive than ocrelizumab.

There is a growing consensus that using highly efficacious disease-modifying therapies (monoclonal antibodies, cladribine, fingolimod) to treat MS early in the disease course reduces the likelihood of disability (9 Treatment references Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more , 10 Treatment references Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more ). Treatments should be tailored to the patient and managed by MS specialists with expertise in their use.

If immunomodulatory medications are ineffective, monthly IV immune globulin may help.

Immunosuppressants other than mitoxantrone (eg, methotrexate, azathioprine, mycophenolate, cyclophosphamide, cladribine) have been used for more severe, progressive MS but are controversial.

Other treatments can be used to control specific symptoms:

Encouragement and reassurance help patients with multiple sclerosis.

Regular exercise (eg, stationary biking, treadmill, swimming, stretching, balance exercises), with or without physical therapy, is recommended, even for patients with advanced MS, because exercise conditions the heart and muscles, reduces spasticity, prevents contractures and falls, and has psychologic benefits.

Vitamin D supplements (eg, 600 to 4000 IU/day to achieve blood levels of 20 to 50 ng/mL [50 to 125 nmol/L] ) may decrease the risk of disease progression (12 Treatment references Multiple sclerosis (MS) is characterized by disseminated patches of demyelination in the brain and spinal cord. Common symptoms include visual and oculomotor abnormalities, paresthesias, weakness... read more ). Serum vitamin D levels should be monitored to make sure that dosing is adequate. Vitamin D also reduces the risk of osteoporosis, particularly in patients at increased risk because mobility is decreased or they take corticosteroids.

Patients should maintain as normal and active a life as possible but should avoid overwork, fatigue, and exposure to excess heat. Cigarette smoking should be stopped.

Vaccination does not appear to increase risk of exacerbations.

Debilitated patients require measures to prevent pressure ulcers Prevention Pressure injuries are areas of necrosis and often ulceration (also called pressure ulcers) where soft tissues are compressed between bony prominences and external hard surfaces. They are caused... read more and urinary tract infections Prevention Bacterial urinary tract infections (UTIs) can involve the urethra, prostate, bladder, or kidneys. Symptoms may be absent or include urinary frequency, urgency, dysuria, lower abdominal pain... read more ; intermittent urinary self-catheterization may be necessary.