Review Question - QID 106113

This patient presents with multiple sclerosis (MS). The first line treatment of an MS flare is high dose IV glucocorticoids.

MS is an autoimmune disorder characterized by inflammation and demyelination of the central nervous system (Illustration A). It most often affects Caucasian women in their 20's and 30's. It can present with a large constellation of neurologic symptoms including: optic neuritis, MLF syndrome, hemiparesis, hemisensory symptoms, and bladder incontinence (Illustration B). It often proceeds via a relapsing and remitting course (Illustration C). On MRI, the characteristic periventricular plaques ("Dawson's fingers") are observed which is characteristic of MS. Treatment of acute flares is high dose IV glucocorticoids. Chronic treatment to prevent relapses include beta interferon, natalizumab, and glatiramer acetate.

Calabresi reviews the diagnosis and management of multiple sclerosis. She states corticosteroids are the treatment of choice for patients with acute, significant symptoms. Disease-modifying agents should be initiated early in the treatment of MS to forestall disease and preserve function. Two immunomodulatory agents (interferon beta and glatiramer) and five immunosuppressive agents (fingolimod, teriflunomide, dimethyl fumarate, natalizumab, and mitoxantrone) are approved by the U.S. Food and Drug Administration for the treatment of MS, each with demonstrated effectiveness and unique adverse effect profiles.

Saguil et al. review the management of MS from a primary care perspective. They state MS is the most common permanently disabling disorder of the central nervous system in young adults. Relapsing remitting MS is the most common type, and typical symptoms include sensory disturbances, Lhermitte sign, motor weakness, optic neuritis, impaired coordination, and fatigue. The diagnosis is clinical and involves two neurologic deficits or objective attacks separated in time and space. Magnetic resonance imaging is helpful in confirming the diagnosis and excluding mimics.

Figure A is an MRI demonstrates the characteristic periventricular plaques or "Dawson's Fingers" representing areas of oligodendrocyte loss and reactive gliosis in MS. Illustration A demonstrates the pathophysiology of demyelination in MS. Illustration B demonstrates the symptoms seen in MS. Illustration C demonstrates the different patterns of MS including relapsing remitting and primary progressive. Illustration D demonstrates the different geographical distributions of MS.

Incorrect Answers:
Answers 1,2: Interferon beta and natalizumab are both treatments for MS to PREVENT acute flares and remissions. However, they are not used as acute treatment in MS flares.
Answer 3: IVIG is not a treatment for MS.
Answer 4: Baclofen can be used for symptomatic treatment of a spastic bladder in MS patients with urinary symptoms. However, this patient has not described urinary symptoms as a problem.