Info

Multiple sclerosis (MS) is characterized by multiple symptoms and signs of brain and spinal cord dysfunction that are disseminated in both time and space. Its pathological hallmark is inflammatory demyelination and axonal lesions; its etiology remains unknown at present despite decades of intensive investigation. A relapse is the appearance of a new neurological disturbance, or the reappearance of one previously present, lasting at least 24 hours. All such disturbances arising within a one-month period are counted as a single relapse. The relapse rate is the number of relapses per year. Clear improvement of neurological function is termed remission.

The course of MS varies greatly from one individual to another, but two basic types of course can be identified: relapsing-remitting (66-85%; most common when onset is before age 25; well-defined relapses separated by periods of nearly complete recovery with or without residual symptoms; does not progress during remission) and chronic progressive. The latter can be divided into three subtypes: primary chronic progressive (9-37%; most common when onset is after age 40; progresses from disease onset onward); secondary progressive (seen in over 50% of cases 6-10 years after onset; initially remitting-relapsing, later chronically progressive; recurrences, mild remissions, and plateau phases may occur); and progressively re-mitting-relapsing (rare; complete remission may or may not occur after relapses; symptoms tend to worsen from one relapse to the next).

Clinical Manifestations

The symptoms and signs of MS reflect dysfunction of the particular areas of the nervous system involved and are not specific for this disease. Typical MS manifestations include paralysis, paresthesiae, optic neuritis (retrobulbar neuritis), diplopia, and bladder dysfunction. Paresis, spasticity, fatigability. Upper-motor-neuron type paralysis of the limbs either is present at onset or develops during the course of MS. Involvement is often asymmetrical and mainly in the legs, especially in the early stage of the disease. Spasticity makes its first appearance in the form of extensor spasms; flexor spasms develop later. The latter are often pain ful, cause frequent falls, and, if severe and persistent, can cause flexion contractures (paraplegia in flexion). Many patients complain of abnormal fatigability.

Sensory manifestations. Episodic or continuous paresthesiae (sensations of tingling or numbness, tightness of the skin, heat, cold, burning, prickling) are common, particularly in the early stage of the disease, with or without other manifestations of neurological dysfunction. As the disease progresses, such positive phenomena usually recede and are replaced by sensory deficits affecting all sensory modalities. A constant or only slowly rising sensory level ("sensory transverse cord syndrome") is uncharacteristic of MS and should prompt the search for a spinal cord lesion of another kind. Many MS patients have Lhermitte's sign (which is actually a symptom), an electric or coldlike paresthesia traveling from the nuchal region down the spine, sometimes as far as the legs, on flexion of the neck (p. 49). If no other symptoms or signs are present, other causes should be considered (e. g., a cervical spinal cord tumor). Pain in MS most often appears in the form of trigeminal neuralgia (p. 186), severe pain in the limbs (p. 108), tonic spasms (p. 204), or backaches, sometimes with radiation in a radicular pattern. Other painful phenomena include flexor spasms due to spasticity, contractures, and dysuria due to urinary tract infection. Visual impairment in MS is usually due to optic neuritis (mostly unilateral), which also produces pain in or around the eye. The impairment begins as blurred or clouded vision and progresses to cause reading impairment and visual field defects (central scotoma or diffuse defects). Marcus Gunn pupils (p. 92) may be observed. Physical exercise, high ambient temperature, menstruation, or cigarette smoking can aggravate existing visual problems (Uhthoff's phenomenon). Optic neuritis, as an isolated finding, is not necessarily the first manifestation of MS; patients with bilateral optic neuritis have a much lower risk of developing MS than those with the unilateral form. Diplopia is usually due to internuclear oph-thalmoplegia (p. 86). Nystagmus (p. 88).

Motor Disturbance

Motor disturbances

(central paresis, spasticity, abnormal fatigability)

Central scotoma (optic neuritis) Nystagmus of abducting eye

Ophthalmoplegia Internuclear Unilateral

Dissociated nystagmus

(internuclear ophthalmoplegia, patient looking to right)

- Adductor paralysis

Dissociated nystagmus

(internuclear ophthalmoplegia, patient looking to right)

Motor disturbances

(central paresis, spasticity, abnormal fatigability)

Atrophy

Atrophy

Temporal papillary atrophy

(after optic neuritis)

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Responses

  • odovacar button
    How do you see with optic neuritis?
    8 years ago

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