Multiple sclerosis (MS)

Multiple sclerosis (MS) is a chronic inflammatory disease characterized by CNS lesions that may lead to severe physical or cognitive disability as well as neurologic defects (Ghasemi, Razavi & Nikzad, 2017). The etiology of MS has been considered a multifactorial disease which includes a genetic predisposition combined with environmental influences such as exposure to infectious agents, vitamin deficiencies, and smoking. Classically presents in white women with ages between 20-40 years old, with temporary visual or sensory loss (Ghasemi, Razavi & Nikzad, 2017). May present with subtle changes in vision, ambulation, and reflexes on examination that provide evidence of previous attacks, which may not have been noticed by the patient. Graying or blurring of vision in one eye can be described as looking through petroleum jelly. May have pain in moving that eye and describe the loss of color discrimination, particularly reds. Patients often describe odd sensations of a patch of wetness or burning, or hemi-body sensory loss or tingling (Ghasemi, Razavi & Nikzad, 2017).

For this patient, I will order an MRI of the brain, MRI of the spinal cord; blood tests such as CBC, CMP, TSH, and Vitamin B12. MRI is the most definitive test for MS. I will further consult a neurologist to interpret the images since they are very familiar with typical MS findings on MRI and in the context of the individual’s history and examination. MRI brain with gadolinium-containing contrast should be performed on all patients with clinical presentation suspicious for MS. MRI views should include sagittal fluid-attenuated inversion recovery (FLAIR) images, which most easily distinguish between MS lesions and non-specific white matter changes (Cerqueira et al., 2016). MRI of the cervical spinal cord is also recommended for all patients to rule out cervical spondylosis. Laboratory evaluations in MS are recommended to exclude MS mimics or diseases that may contribute to MS symptoms, such as thyroid disease, vitamin B12 deficiency, and diabetes mellitus (Cerqueira et al., 2016).

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Patients diagnosed with MS will highly likely develop UTI, depression, visual impairment, and impaired mobility. Patients with urinary tract infections may present only with neurologic worsening (Cerqueira et al., 2016). Urinary tract infections should be treated appropriately and preventive measures considered, such as increased hydration, control of constipation, and prophylactic antibiotics. Depression is due to multifactorial causes such as sleep disturbance and situational response. Therefore, consultation with a mental healthcare provider may be helpful. Visual complications of MS are a primary manifestation of the disease. Patients should be seen by an experienced ophthalmologist, preferably a neuro-ophthalmologist, to make sure that symptoms are truly MS-related (Cerqueira et al., 2016). Impaired mobility is treated with disease-modifying therapy that is directed in preventing progression, with variable effectiveness. Patients should be seen by an experienced physical therapist that can assist with the prescription of appropriate devices including ankle-foot orthosis and 4-wheeled walkers with hand brakes, which are preferred for MS patients due to stability issues. There are no clear strategies for primary prevention other than encouraging at-risk individuals not to smoke and possibly taking a multivitamin containing vitamin D (Cerqueira et al., 2016).

The onset of MS is infrequent and atypical after 50 years – late-onset multiple sclerosis (LOMS) and more so over 60 years – very late-onset multiple sclerosis (VLOMS) (Sanai et al., 2016). Ambulation and other physical capacities decline more rapidly in the aged MS patients. Likewise, in the psychological perspective, MS-associated psychological symptoms occur more frequently in the elderly as compared to younger patients (Sanai et al., 2016). Within an elderly MS patient group, the study showed 52.8% reported having frequent depressed feelings and moods, and 30.2% had suicidal ideation. Interestingly, while depression and fatigue remain common in older-aged MS patients, the prevalence of anxiety actually decreases (Sanai et al., 2016).

References:

Cerqueira, J. J., Compston, D. A., Geraldes, R., Rosa, M. M., Schmierer, K., Thompson, A., Palace, J. (2018). Time matters in multiple sclerosis: Can early treatment and long-term follow-up ensure everyone benefits from the latest advances in multiple sclerosis? Journal of Neurology, Neurosurgery & Psychiatry, 89(8), 844-850. doi:10.1136/jnnp-2017-317509

Ghasemi, N., Razavi, S., & Nikzad, E. (2017). Multiple Sclerosis: Pathogenesis, Symptoms, diagnoses and Cell-Based Therapy. Retrieved April 14, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5241505/

Sanai, S. A., Saini, V., Benedict, R. H., Zivadinov, R., Teter, B. E., Ramanathan, M., & Weinstock-Guttman, B. (2016). Aging and multiple sclerosis. Multiple Sclerosis Journal, 22(6), 717-725. doi:10.1177/1352458516634871

 

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