MS sufferers hope for respite
BY Dr. Khaldoun Mozahem, M.D.
Multiple sclerosis is a chronic disease of the central nervous system, i.e. brain and spinal cord. It is an immune system disorder where specialized white cells are activated, leading to an attack on the insulation of the nerve processes, which are known as myelin.
The neuron, or nerve cell, is the main unit of the nervous system. It has a cell body that receives signals from other neurons via short extensions called dendrites, and processes them before sending new signals out to other nerve cells through a long extension called an axon. These extensions are engulfed by a myelin sheath.
The inflammation caused in the case of multiple sclerosis leads to the removal of parts of the myelin sheath, that is demyelination.
Axonal loss and atrophy also may be seen. The main feature of multiple sclerosis is the formation of plaques which are seen in the white matter of central nervous system. White matter is composed of myelinated axons arranged together, and the color of myelin is white in contrast to gray matter which is composed of cell bodies and dendrites.
White matter is found in the core of the brain and surface of the spinal cord. In the case of multiple sclerosis, the areas of inflammation would change; there is always injury and repair, leading to resolution of inflammation, or leaving scarring or atrophy.
Multiple sclerosis is a disease of young people, affecting females more than males. Prevalence is unequal throughout the world, seen the most in Europe and North America, where it may reach one in 1000.
Multiple sclerosis rarely starts before the age of 15 or after 50, with most of the patients presenting symptoms between the ages of 25 and 40 years old.
The cause of multiple sclerosis is unknown but it seems that a combination of genetics with environmental factors leads to the disease, but no clear reason has been defined yet. It could be something like a virus which may irritate the immune system in a susceptible person, as decided by genetics, and start the inflammatory process leading to features seen in multiple sclerosis. Up to one fifth of patients may have an affected relative. People who immigrate to a high prevalence country will have the same risk of that country if they migrated before age 15, while they keep their country of origin prevalence if they did after age 15. Sunlight and Vitamin D could be protective.
Sensory loss, weakness, and visual loss, are the common symptoms at the onset of multiple sclerosis. Any neurological function can be affected by the disease process, which is gait and balance, bladder and bowel function, mental health, and special senses. Additionally, psychiatric symptoms could appear as a side effect of multiple sclerosis medication, or as a reaction to the disease. Other common symptoms of multiple sclerosis which could be severe enough to impact quality of life include fatigue, spasticity (inability to relax muscles), sexual dysfunction and cognitive impairment.
The most common type of the disease is “relapsing remitting multiple sclerosis,” which may happen very frequently, every month or happen only once in lifetime. In some cases, patients were diagnosed by an autopsy and not during their lifetime. Patients are usually symptom free between the early attacks, but later a lasting deficit may develop with further attacks, leading to disability. In progressive multiple sclerosis, patients gradually get worse with no symptom-free periods.
The diagnosis of multiple sclerosis relies mainly on the patient history and examination findings that have to be supported by tests for confirmation, or to rule out other diseases which may present similar symptoms. Plaques of multiple sclerosis may be seen on magnetic resonance imaging which is an advanced method of imaging body parts, and relies on electromagnetic fields comparatively to X-rays in computed tomography. Lumbar puncture may help by showing evidence of inflammation in the central nervous system. Evoked potentials tests, blood tests or other tests may be obtained, too.
There is no cure for multiple sclerosis but fortunately there are a variety of medications which may help lower the impact of the disease and improve the patient’s quality of life. In the case of an acute attack, a type of cortisone called Solumedrol can be used in high doses as an intravenous infusion over the course of a few days to abort inflammation and speed up recovery. Using the medication intravenously is necessary to avoid stomach discomfort, and the unfortunate side effects of using cortisones for long periods of time are not seen with the short intravenous use. The patient may report a metallic taste, transient insomnia, or fatigue. Electrolyte imbalance, glucose intolerance, and hypertension are rare.
Medications used to prevent attacks of the disease are called disease modifying drugs. The current effective drugs came into use in early 1990s. They changed the natural history of disease, and as a result we do not see too many patients with disabilities like we used to before 1990, when many patients ended up in nursing homes. Injectable medications, subcutaneously, intramuscularly, or intravenously, came first. Later, the pharmaceutical industry introduced oral medications. Currently we have more than 10 drugs available in our armory to fight multiple sclerosis that work on modifying an abnormal reaction in the immune system. Unfortunately, they are expensive, and have to be taken for a long period of time, and in some cases for a lifetime unless there are significant improvements in future medications. There are many promising therapies that are being researched and may be introduced to the market soon.
As a doctor, an important aspect of the disease management is to attend to the patient’s quality of life issues and discuss their daily living activities with them and their families.
This is done best through a multidisciplinary team which includes a neurologist, psychiatrist, psychologist, physiotherapist, occupational therapist, social worker, nurse and pharmacist. In a lot of countries, multiple sclerosis societies are formed to create a channel for patients and their families to meet on a regular basis to get educated and exchange thoughts and ideas.
For women who wish to conceive, disease modifying drugs should not be used during pregnancy; the good news is that disease activity becomes less, for unknown reasons, during pregnancy. Disease modifying drugs are not allowed during lactation, too.
Right after delivery the disease may flare up, therefore the period of lactation may be shortened to allow the patient to resume the drug. It is important for young women to discuss such details with their physician as needs and challenges may differ among patients.
In conclusion, multiple sclerosis is a relatively common neurological disease. There are many ways to seek help. It is important for patients to be active members of the society. We are hoping to have a cure for multiple sclerosis in the near future.
Dr. Khaldoun Mozahem M.D. is a neurology consultant and sleep medicine specialist at American Center of Psychiatry and Neurology