• Lena HorneLena Horne

• Richard PryorRichard Pryor

• Montel WilliamsMontel Williams

• Clay WalkerClay Walker

• What do all of these celebrities What do all of these celebrities have in common?have in common?

• They all have They all have Multiple Multiple SclerosisSclerosis

Multiple SclerosisMultiple Sclerosis

Peter Valenzuela, MD, MBAPeter Valenzuela, MD, MBAAssistant Dean for Clinical Affairs/Assistant ProfessorAssistant Dean for Clinical Affairs/Assistant Professor

Texas Tech University Health Sciences Center at the Permian Texas Tech University Health Sciences Center at the Permian BasinBasin

OverviewOverview

• Description including prevalence Description including prevalence and possible causesand possible causes

• Signs and SymptomsSigns and Symptoms• Diagnosis including differentialDiagnosis including differential• TreatmentTreatment

Incidence/PrevalenceIncidence/Prevalence

• Affects 400,000 Americans; 2.5 Affects 400,000 Americans; 2.5 million people worldwidemillion people worldwide

• 2-3 times more common in 2-3 times more common in Caucasian womenCaucasian women

• Most often in people between 20-Most often in people between 20-50 years old50 years old

• Greater frequency in higher Greater frequency in higher latitudes (above 40 degrees) latitudes (above 40 degrees)

DescriptionDescription

• Myelin-covers axons and improves Myelin-covers axons and improves conduction between neuronsconduction between neurons

• Auto-immune destruction of myelin Auto-immune destruction of myelin results in scarring or results in scarring or sclerosissclerosis

• Symptoms depend on location of Symptoms depend on location of myelin destroyedmyelin destroyed

Cause/Risk FactorsCause/Risk Factors

• Cause-Cause- Unknown, Unknown, immune-immune-mediated mediated

• Genetics?Genetics?• Northern European descentNorthern European descent• Higher incidence in direct relativesHigher incidence in direct relatives

• Infection?Infection?• Chlamydia pneumoniae, HSV, EBVChlamydia pneumoniae, HSV, EBV

Cause/Risk FactorsCause/Risk Factors

• Geographic Geographic location?location?• 40 degrees 40 degrees

latitude above latitude above equatorequator

• Risk level varies Risk level varies with length of with length of time spent in areatime spent in area

Cause/Risk FactorsCause/Risk Factors

• HormonesHormones• More common in womenMore common in women

• ExposureExposure• Clusters- Lead, Arsenic, ZincClusters- Lead, Arsenic, Zinc

Signs and SymptomsSigns and Symptoms

• Neuro: Neuro: • Paralysis, altered sensation Paralysis, altered sensation • Tremors, poor coordinationTremors, poor coordination• Visual loss, Visual loss, optic neuritisoptic neuritis

• Musculo-skeletal: Musculo-skeletal: • FatigueFatigue • SpasticitySpasticity

Signs and SymptomsSigns and Symptoms

• GI:GI:• ConstipationConstipation• DiarrheaDiarrhea• IncontinenceIncontinence

• Gu:Gu:• UrgencyUrgency• HesitancyHesitancy• IncontinenceIncontinence

Signs and SymptomsSigns and Symptoms

• Cognitive and EmotionalCognitive and Emotional• Poor memoryPoor memory• Delayed processing Delayed processing • Depression- 50% of patientsDepression- 50% of patients

• Sexual DysfunctionSexual Dysfunction• Impaired libidoImpaired libido• Sexual inadequacySexual inadequacy• Sexual dysfunctionSexual dysfunction

Differential DiagnosisDifferential Diagnosis

• Auto-immuneAuto-immune• Polyarteritis Nodosa, Systemic Lupus Polyarteritis Nodosa, Systemic Lupus • Sjögren's, SarcoidosisSjögren's, Sarcoidosis

• InfectionInfection• Lyme Disease, NeurosyphilisLyme Disease, Neurosyphilis• HIV, JC Virus-Progressive Multifocal HIV, JC Virus-Progressive Multifocal

leuko-encephalopathyleuko-encephalopathy

Differential DiagnosisDifferential Diagnosis

• Genetic DisordersGenetic Disorders• Leukodystrophy, Mitochondrial Leukodystrophy, Mitochondrial

diseasedisease

• Compressive DisordersCompressive Disorders• Tumor, Herniated disc, Chiari Tumor, Herniated disc, Chiari

malformation malformation

• B12 DeficiencyB12 Deficiency

DiagnosisDiagnosis

• MRI:MRI:• Multiple white Multiple white

matter lesions matter lesions (plaques) in (plaques) in different areas of different areas of CNS at different CNS at different points in timepoints in time

DiagnosisDiagnosis

• CSF AnalysisCSF Analysis• Oligoclonal bands by electrophoresisOligoclonal bands by electrophoresis• high IgG levelshigh IgG levels• Increased WBCs (>5 cells/µL)Increased WBCs (>5 cells/µL)

• Evoked PotentialsEvoked Potentials• VER, BAER, SERVER, BAER, SER• VER is most sensitiveVER is most sensitive

Diagnostic Criteria for Diagnostic Criteria for MSMS

• Clinical PresentationClinical Presentation• Additional DataAdditional Data• McDonald’s CriteriaMcDonald’s Criteria

Course/PrognosisCourse/Prognosis

• Benign: 10%Benign: 10%• Relapsing-Relapsing-

Remitting: 40%Remitting: 40%• Secondary Secondary

Chronic Chronic Progressive: 40%Progressive: 40%

• Primary Primary Progressive: 10%Progressive: 10%

Treatment Treatment

• Immune modulatorsImmune modulators• Avonex, Betaseron, Copaxone, RebifAvonex, Betaseron, Copaxone, Rebif

• Anti-spastic drugsAnti-spastic drugs• Stretching & Exercise (Yoga, PT)Stretching & Exercise (Yoga, PT)• Lioresal, Neurontin, ZanaflexLioresal, Neurontin, Zanaflex

• DysesthesiasDysesthesias• Dilantin, Elavil, Neurontin, Tegretol Dilantin, Elavil, Neurontin, Tegretol

TreatmentTreatment

Bladder and UrineBladder and Urine• Ditropan, Detrol, CarduraDitropan, Detrol, Cardura• Self-catheterizationSelf-catheterization

• TremorTremor• INH, Neurontin, Inderal, XanaxINH, Neurontin, Inderal, Xanax

• Fatigue/DepressionFatigue/Depression• Eldepryl, Symmetrel, ProvigilEldepryl, Symmetrel, Provigil• Prozac, PaxilProzac, Paxil

Treatment for RelapsesTreatment for Relapses

• Treat source of exacerbationTreat source of exacerbation• Sinusitis, bronchitis, UTISinusitis, bronchitis, UTI

• SteroidsSteroids

Annual Cost for Annual Cost for MedicationsMedications

• Immune Modulators- $18,000Immune Modulators- $18,000• Anti-spastics- $1,700Anti-spastics- $1,700• Dysesthesia- $2,600Dysesthesia- $2,600• Tremor- $1,200Tremor- $1,200

Annual Cost for Annual Cost for MedicationsMedications

• Fatigue- $3,100Fatigue- $3,100• Depression- $300Depression- $300• Bladder and Urine- $2,160Bladder and Urine- $2,160

Total Annual Cost for Total Annual Cost for Medications Could Reach Medications Could Reach

over $30,000!over $30,000!

SummarySummary

• Description including Description including prevalence and possible prevalence and possible causescauses

• Signs and SymptomsSigns and Symptoms• Diagnosis including differentialDiagnosis including differential• TreatmentTreatment

Questions?Questions?

ReferencesReferences

• Calabresi P. Diagnosis and Management of Calabresi P. Diagnosis and Management of Multiple Sclerosis. American Family Physician Multiple Sclerosis. American Family Physician 2004; Vol. 70:10, 1935-43.2004; Vol. 70:10, 1935-43.

• Dynamed website (Accessed Dynamed website (Accessed October 2, 2006)October 2, 2006)

• National Multiple Sclerosis Society National Multiple Sclerosis Society at at www.nationalmssociety.orgwww.nationalmssociety.org (Accessed October 2, 2006)(Accessed October 2, 2006)

• www.jsumption.comwww.jsumption.com (Acessed (Acessed October 3, 2006)October 3, 2006)

ReferencesReferences

• www.msfocus.orgwww.msfocus.org (Accessed (Accessed October 4, 2006)October 4, 2006)

• http://www-medlib.med.utah.eduhttp://www-medlib.med.utah.edu// (Accessed October 6, 2006)(Accessed October 6, 2006)

• Epocrates database (Accessed Epocrates database (Accessed October 10, 2006October 10, 2006

• http://www.mult-sclerosis.org/famohttp://www.mult-sclerosis.org/famous.htmlus.html