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Multiple sclerosis (MS)

Overview

MS is an inflammatory demyelinating disorder of the central nervous system (CNS). MS occurs rarely before puberty and after the age of 60 years. Peak incidence occurs between 30 and 40 years of age. The episodes are often triggered by smoking, deficiency of vitamins D or B12, and higher altitudes.

  • Exact cause is unknown
  • May be attributed to a combination of environmental and genetic factors

  • Genetics: A gene on chromosome 6p21 is associated with MS, and about 200 genes contribute to the MS risk
  • Family history
  • Female sex 
  • Age range 20 to 40 years
  • Race: White people, especially those from Northern Europe, are at the highest risk.
  • Climate: MS is more common in temperate climates, such as Canada, the northern United States, and Europe
  • Low vitamin D levels
  • Obesity
  • Smoking; second-hand smoke exposure may be related to the risk of paediatric MS.
  • Epstein-Barr virus (EBV)
  • Gut dysbiosis

Symptoms depend on the structure involved in neuraxis

  • Transverse myelitis
    • Weakness, sensory symptoms
    • Urinary urgency and retention
    • Flexor spasms
    • Spastic quadra or paraparesis
    • Sensory level
  • Brainstem
    • Ataxia
    • Diplopia
    • Dysarthria
    • Facial numbness
    • Internuclear ophthalmoplegia
    • Gaze palsy
    • Rubral tremor
  • Cerebellum
    • Ataxia
    • Dysarthria
    • Nystagmus
  • Optic neuritis
    • Visual loss
    • Painful eye movements
    • RAPD (relative afferent pupillary defect)
    • Impaired colour vision (Ishihara colour plates)
    • Decreased acuity
    • Optic atrophy
  • Cerebral hemispheres:
    • Poor memory
    • Disinhibition
    • Dementia
    • Epilepsy (rarely)
    • Lhermitte’s symptom (Neck flexion causes current like sensation or tingling)
    • Uhtoff’s phenomenon, which is worsening of symptoms, e.g. vision, when body temperature is raised due to hot shower or exercise
    • Internuclear ophthalmoplegia (impaired adduction on abducting the other eye)

85% of patients experience relapse or disease remittance (RRMS), 50–60% experience the secondary progressive phase (SPMS), and 10% have primary progressive disease (PPMS) with gradual accumulation of disability.

  • MRI to determine T2W high signal changes in the corpus callosum, periventricular white matter, and brainstem
  • McDonald criteria
  • Evoked responses evaluation:
    • Visual evoked responses (VER): delayed even after the recovery of optic neuritis
    • Somatosensory evoked potentials (SSEP)- delayed in cases of spinal cord lesions.

Neurologist

  • Corticosteroids
  • Disease-modifying therapy (DMT) : Interferons, Glatiramer acetate, Monoclonal antibodies natalizumab, rituximab, alemtuzumab
  • Supportive treatment for spasticity, bladder dysfunction, fatigue
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