Transcript Multiple sclerosis (MS) –

Multiple sclerosis (MS) –
is a chronic disease that begins
most commonly in young adults
and is characterized pathologically
by multiple areas of central
nervous system (CNS) white matter
inflammation, demyelination, and
glial scarring (sclerosis)
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Etiology
The cause of MS is unknown. There are 2 groups of
possible reasons of the disease:
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Genetic susceptibility
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Environmental factors
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Infections (the virus can influence on nervous system
directly or through the autoimmune mechanisms).
Geographical (ground, water properties, the number
of light days in a year)
Toxic
Social conditions
Diet (domination of meat in the diet)
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Other factors (trauma)
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The typical features of MS
pathogenesis
 Clinical and immune signs are closely
connected with each other in MS patients.
Usually immune signs are the first ones
 There is disturbance of activating and
suppressing cytokines balance
 The immunity is changed in the course of the
disease
 There are signs of immune suppression and
immune modulation according to the stage of
the disease – exacerbation or remission
Myelin function
Pathology
 There are multiple areas of Central
Nervous System white matter
inflammation, demyelination and glial
scarring (sclerosis). The lesions are
multiple in space. They are located in:
 spinal cord
 cerebellum
 Optic n.
 brain white substance
The beginning of the disease
 Paresthesia. It is the feeling of numbness or tingling in
one of the extremity. It can be spread during the next 3 – 4
days and lasts for about 1 – 2 weeks, then gradually
disappear.
 Motor disorders - weakness in lower extremities. This
symptom is much more common at the age of 25 – 40
years.
 Retrobulbar neuritis is a progressive loss of vision, colour
vision disturbances. It lasts for about several weeks.
 Oculomotor n. disorders (diplopia and cross eye).
 Pelvis disorders (retention of urine, micturition)
 Acute vestibular syndrome
 Cerebellar disorders – ataxia, disorders of coordination.
Typical clinical features
 Motor disorders – 89 – 97%
 Ataxia – cerebellar, sensitive and vestibular – 62 –
74%
 Sensory disorders – pains and sensitive ataxia - 72 –
74%
 Brain stem symptoms – vestibular syndrome,
dysarthria, CN’s lesion – 47 – 58%
 Visual and eye movements disorders – 42 – 52%
 Autonomic disturbances – pelvic and sexual
disorders – 46 – 60%
 Nonspecific symptoms – cognitive, memory
disturbances, loss of attention – 62%
 Paroxysmal symptoms
Visual field disorders of MS
Clinical forms
Cerebral :
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cortical (epileptic attacks, psychiatric disorders)
Visual
brain stem
cerebellar.
Spinal:
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Cervical
Thoracic
lumbar – sacral
pseudotabes.
Cerebrospinal
The course of the disease
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Acute
Subacute
Chronic:
– remittent,
- remittent – progressive
- progressive – remittent
- progressive
The periods of the disease:
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Exacerbation
Remission (complete, incomplete).
Stable period
MS degree:
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I, II, III, IV, V
Scale of MS disability (EDSS)
MS diagnosis
 Immune examinations of blood and CSF. Usually
there are increased Ig G, M, A contents.
 Insignificant increasing of protein content and
moderate pleocytosis in CSF
 Lymphocytosis, eosynophilia – in exacerbation
stage; leukopenia, lymphopenia – in the period of
remission.
 Increased thrombocytes aggregation and fibrinogen
content.
 Increased Ig content in serum and decreased T –
lymphocytes quantity.
 To put veridical MS we have to reveal in
patient at least 2 focuses of lesion and 2
exacerbations, or 2 exacerbations of 1
clinical focus and 1 paraclinical supposed
focus.
 According to the accepted criteria there
should be at least 3 focuses in MRI (2 of
them should be located paraventricularly, 1
– subtentorialy (that means in brain stem or
cerebellum). The diameter of focuses
should be at least 6 mm, or there should be
4 focuses, 1 of them periventricularly.
MRI of MS
MRI of MS
Sagittal T1-weighted MRI depicts multiple hypointense
lesions in the corpus callosum; this finding is
characteristic of MS
Coronal fluid-attenuated inversion recovery (FLAIR) MRI in a
patient with multiple sclerosis demonstrates periventricular
high–signal intensity lesions, which exhibit a typical distribution
for MS. FLAIR MRI is a highly sensitive sequence for lesion
detection, particularly supratentorially
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Axial T2-weighted MRI in a patient with multiple sclerosis
demonstrates numerous white matter plaques in a callosal and
pericallosal white matter distribution.
Spinal form of MS
 One of the limitations of using MRI in
patients with MS is the discordance
occurring between lesion location and the
clinical presentation. In addition, depending
on the number and location of findings, MRI
can vary greatly in terms of sensitivity and
specificity in the diagnosis of MS. This is
especially true of primary progressive MS,
which may not show the classic discrete
lesions of relapsing-remitting MS.
 A clinician presented with an MRI report that details
a few "nonspecific white matter lesions" that are
"compatible with MS" is often frustrated with the
lack of sensitivity and specificity of such a
description. For this reason, imaging findings need
to be described in detail, and preferably referenced
to one of the published set of diagnostic criteria
such as those by Paty or Barkhof. Finally, the
specific patient's neurologic history and clinical
findings must be correlated with the imaging to
establish an accurate diagnosis
 Cerebrospinal fluid (CSF) analysis for
oligoclonal banding or immunoglobulin G
(IgG) levels is no longer routine in the
investigation of MS, although this test
may be of use when MRI is unavailable
or MRI findings are nondiagnostic
Treatment
Pathogenetical treatment
 Corticosteroids and ACTH
 Cytostatics and immune modulators,
non specific immune suppressors
 Cytokines, interferones
 Antigen – specific immune therapy
Corticosteroids and ACTH
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Prednisone is used orally 1 – 1.5 mg/kg/day twice a day
during 10 – 14 days. Then during the next 2 months we
decrease the dose gradually.
One of the most popular schema for
Methylprednisolone usage is 500 – 1000 mg per day i/v
in 500 ml of physiological solution during 3 – 5 days.
Then Prednisone is used in dose 0.5 – 1 mg/kg during 3
– 7 days with gradually decreasing of dose during the
next 2 – 3 weeks. This way of usage has much more
expressed and quick effectiveness and insignificant
outside effects
Dexamethasone is used i/v or i/m according to the
schema – 8 mg per day during 7 days, 4 mg – 4 days, 2
mg – 3 days. It is used at retrobulbar neuritis
The peculiarities of
Corticosteroids usage:
 Long lasting and frequent usage is undesirable
 Usually H-2 blockers are used together with
Corticosteroids
 ACTH has immune suppressive activity,
inhibits cellular and humoral immunity. It is
used in dose 40 – 100 U i/m during 10 – 14
days.
 Plasmapheresis is used in case of
exacerbation.
Cytostatics and immune modulators,
non specific immune suppressors
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Asatioprine, Cyclophosfamidum,
Cyclosporinum A. But all of these medicines
have a lot of outside effects.
The representatives of immune modulators are - T –
activinum, Timalinum, Myelopid, Levamisolum. They
are prescribed at progressive forms of MS.
T – activinum is used in dose 100 mcg s/c every
evening during 5 days, then 1 – 3 injections every 10
days.
Timalinum is used in dose 10 mg i/m twice a day
during 5 days, then every 10 days 2 injections are
used.
Interferones
There are 3 types of Interferonum – α, β, γ.
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α - Interferonum has neither toxic nor treating
activity.
γ - Interferonum activates immune system and
that’s why it provokes exacerbations.
β - Interferonum inhibits production of γ –
interferonum, increases activity of T –
suppressors, has antiproliferative, antiviral and
immune modulating properties.
Rebif – is a modern human β – interferonum
produced by “Serono” production and is used for
MS treatment. It is used in dose 6 – 12 mln s/c
three times per week. It is one of the most
effective modern medicines in MS patients, but
unfortunately it is very expensive
Antigen – specific immune therapy
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One of the representatives of these
medications is Copaxone, made in Israel.
Cost of treatment is about 7 000 $. It is
used in dose 20 mg per day s/c during 6 –
24 months. It has selective immune
modulating action.
Acute multiple
encephalomyelitis (AMEM)
It is an infectious – allergic
disease that is
characterized by acute
multiple lesion of the brain
and spinal cord
Clinical forms
 Encephalomyelopoliradiculoneuritis – it is the
most common form of the disease, which is
characterized by the lesion of all parts of nervous
system.
 Polioencephalomyelitis – it is characterized by
the lesion of CN’s nuclei and spinal cord gray
substance.
 Opticoencephalomyelitis and opticomyelitis –
are characterized by optic nerve neuritis and
symptoms of lesion of brain and spinal cord.
 Disseminated myelitis – the spinal cord is
damaged on different levels.
Treatment
 Corticoids: Prednisolone and
Methylprednisolone in dose 10 – 15 mg per kg
i/v by drops per day. Later we can use it in pills 1.5 – 2 mg/kg every other day.
 Together with this medicine we prescribe
anabolics , K, Ca, vitamin C.
 In acute stage we prescribe desensibilizating
and dehydrating medicines. In case of severe
bulbar disorders we include resuscitation
measures.
 Plasmapheresis and vitamin B are also used.
 In residual period we prescribe massage, dibasol,
KJ, biostomulants, Lidasa, Seduxen, sanatorium
treatment.
Clinical symptoms of MS