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Multiple Sclerosis (MS)

Overview

Multiple sclerosis is an autoimmune disease of the nervous system in which your body’s immune system reacts abnormally against the protective covering (myelin sheath) around the nerves present in your brain and spinal cord, Due to which, the nerves are unable to send signals to the rest of the body, and so affecting communication between the brain, spinal cord, and the body. Due to varying amounts of destruction, the symptoms can range from paraesthesias (pin-like sensations) to paralysis. . It is a chronic illness characterized by acute attacks of neurological symptoms that are months or years apart and affects different parts of the body resulting in physical and mental disability.
The actual cause of the disease is unknown, but a combination of genetic and environmental factors is thought to play a role. Environmental factors such as smoking, viral infection, low Vitamin D levels can trigger a reaction in genetically susceptible patients.
Multiple sclerosis is incurable. It is managed by controlling the acute symptoms and preventing further episodes.

Causes

The exact cause of the disease is unknown; however, it is thought to result from a combination of genetic and environmental factors. Your immune system is programmed to attack the bacteria, viruses, and foreign cells; however, in some people, triggers such as viral infection, smoking, low levels of Vit D can disturb the immune system, which then starts a series of inflammatory reactions and cause damage to the myelin sheath which is a protective covering around your nerves of the brain and spinal cord.

Types

  • The disease is classified into various types depending upon the appearance of symptoms, remissions, progression. These types are important to predict future episodes and even guide the treatment.
  • Relapsing-Remitting MS (RRMS) is the common type (80%) in which periods of acute symptoms are followed by complete absence. The acute episodes may or may not leave permanent disability.
  • Secondary Progressive MS (SPMS): this is the next common type (65%) in which the RRMS type may ultimately become progressive with little or no remissions at all.
  • Primary Progressive MS (PPMS): in a few (10-20%) people, the disease takes a progressive course since the beginning with little or no remissions at all. The peak age for this group is around 40 years. It causes progressive neurological deficits.
  • Progressive-Relapsing MS (PRMS): this type is uncommon in which there are acute flares of severe illness in already progressive disease.

Epidemiology

According to Medscape, MS affects around 2.1 million people across the world. Some geographical and racial factors may affect the prevalence of MS; for instance, it is found more in the southern and northern poles than in the equatorial regions. It is more prevalent in females and affects ages between 15-45 years. The peak ages for diagnosis are 29 years for females and 31 years for males.

Risk Factors

Certain factors put you at high risk of inflammation.

  • Family history
  • Female gender
  • Low levels of vitamin D
  • Smoking
  • Viral infections
  • Living in High latitudes: e.g., Alaska; Washington, New York, Scandinavia; Canada; New Zealand and southernmost Australia, northern parts of the United Kingdom, Wisconsin
  • Presence of other autoimmune diseases

Signs and Symptoms

The episodes of MS cause symptoms related to the nervous system. The episodes are accompanied by periods of remission, which vary in every individual. In each episode, a person may experience different symptoms; for example, If a person had problems in the eye in one episode, he may have symptoms related to the leg in the next episode that occurs after the remission.
The different possible symptoms can be:

  • Sensory sensations like feeling numb or pins-like
  • Muscle cramps and spasticity
  • Bowel, Bladder, or sexual dysfunction
  • Problems with speech, crossed eyes, and intention tremor
  • Blurring of the vision or loss of vision if your nerve of the eye is affected ( optic neuritis)
  • The feeling of weakness or paraesthesias on both sides of the face
  • Irregular twitching of the muscles of the face
  • An acute flare of symptoms can occur due to high temperatures
  • Fever, fatigue, exhaustion
  • Difficulties with concentration, attention, memory, and judgment
  • Depression or mania or bipolar disorder

Diagnosis

The specific pattern of signs and symptoms is sufficient for diagnosis; however, your doctor may advise some tests to confirm the diagnosis in complex cases or rule out other possible disorders.
MRI: MRI scan is the most common investigation ordered. It can show specific lesions of demyelination in the brain. You may be given an injection in the vein of the contrast agent that will further highlight the findings.
Lumbar Puncture: is the procedure in which fluid in your brain and spinal cord, called cerebrospinal fluid, is taken out by a needle inserted in your vertebral column. It may show specific findings of MS, like oligoclonal bands, which are proteins of inflammation.
Evoked Potentials: in this test, visual or electrical stimuli are given, and the activity of signals in your nerves is measured using special devices. In MS, the activity is slowed down or absent.

Differential Diagnosis

Some other disorders may produce signs and symptoms similar to that of MS;

  • Tumors of the spinal cord
  • Sarcoidosis
  • Infarction of the spinal cord
  • Subacute combined degeneration of the spinal cord (vitamin B12 deficiency)
  • Transverse myelitis

Treatment

  • Although there is no complete cure for MS, many medicines have been used to modify the immune reactions to prevent progression and treat acute symptoms.
    Acute Attacks: acute attacks are treated by giving injections of high-dose steroids (prednisolone). If steroids are contraindicated or not effective, then plasmapheresis can be used. Plasmapheresis is a procedure in which the diseased part of your blood is removed and filtered using special devices and then returned to the body
    Disease-Modifying Treatments:
  • Interferons: these were the first medicines to be approved and are the most commonly used. They are of different classes like interferon beta 1a and 1 b, peginterferon beta 1a, and are available as injections.
  • Monoclonal Antibodies. These are antibodies produced in the laboratory that alter the immune system.  (eg, ocrelizumab, alemtuzumab, natalizumab)
    Sphingosine 1-Phosphate Receptor Modulators: these are oral medicines and work by acting at lymphocytes, although the exact mechanism is not well understood. Eg Fingolimod, Siponimod.
  • Many other medicines are used that modulate your immune system (e.g., glatiramer, cladribine, teriflunomide, monomethyl fumarate)

Prognosis

Multiple sclerosis is a lifelong disease accompanied by relapses and remissions. Some people have a slow course, while in others, the condition is intense and progressive and may result in severe disabilities like paralysis, particularly of legs, losing bladder and bowel control, depression and mood changes, sexual problems, etc. Earlier, the diagnosis is made, the treatment is started, so better outcomes are possible.

Lifestyle Changes

The disease progression and severity can be controlled by adopting some changes in lifestyle like;

  • Gentle exercises can have a good impact on your muscle spasms and disability.
  • Consuming a healthy diet rich in vitamins, minerals, omega 3 fatty acids, antioxidants can help.
  • Taking rest and avoiding stress would be beneficial as stress flares the disease.
  • Taking measures to reduce the risks of falls must be practiced.
  • Staying connected to support groups and comprehensive websites may help.