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Case: Multiple Sclerosis Risk Factors

DEFINITION OF TERMS These factors may increase your risk of


Myelin sheath- Myelin developing multiple sclerosis:

Myelin is an insulating layer, or Age. MS can occur at any age, but


sheath, that forms around nerves, most commonly affects people
including those in the brain and spinal between the ages of 15 and 60.
cord. It is made up of protein and fatty
substances. Sex. Women are about twice as
likely as men are to develop MS.
The purpose of the myelin sheath is to
allow electrical impulses to transmit
Family history. If one of your
quickly and efficiently along the nerve
parents or siblings has had MS, you are
cells. If myelin is damaged, the impulses
at higher risk of developing the
slow down
disease.

Certain infections. A variety of


viruses have been linked to MS,
including Epstein-Barr, the virus that
causes infectious mononucleosis.

Definition of the disease: Race. White people, particularly

Multiple sclerosis (MS) is a disease in those of Northern European descent,


which your immune system attacks the are at highest risk of developing MS.
protective sheath (myelin) that covers People of Asian, African or Native
your nerves. Myelin damage disrupts
American descent have the lowest risk.
communication between your brain and
the rest of your body. Ultimately, the
nerves themselves may deteriorate, a Climate. MS is far more common
process that's currently irreversible in countries with temperate climates,
including southern Canada, northern
United States, New Zealand,
Epidemiology southeastern Australia and Europe.

Certain autoimmune
diseases. You have a slightly higher
risk of developing MS if you have
thyroid disease, type 1 diabetes or
inflammatory bowel disease.
Smoking. Smokers who Your doctor is likely to start with a
experience an initial event of thorough medical history and
symptoms that may signal MS are examination. Your doctor may then
more likely than nonsmokers to recommend:
develop a second event that confirms
relapsing-remitting MS. Blood tests, to help rule out
infectious or inflammatory diseases
with symptoms similar to MS.

Causes Spinal tap (lumbar


puncture), in which a small sample of
The cause of multiple sclerosis is fluid is removed from your spinal canal
unknown. It's believed to be an for laboratory analysis. This sample
autoimmune disease, in which the body's can show abnormalities in white blood
immune system attacks its own tissues. In cells or antibodies that are associated
MS, this process destroys myelin the with MS. Spinal tap can also help rule
fatty substance that coats and protects out viral infections and other
nerve fibers in the brain and spinal cord. conditions with symptoms similar to
MS.
Myelin can be compared to the insulation
on electrical wires. When myelin is MRI, which can reveal areas of MS
damaged, the messages that travel along (lesions) on your brain and spinal cord.
that nerve may be slowed or blocked. You may receive an intravenous dye to
highlight lesions that indicate your
It isn't clear why MS develops in some disease is in an active phase.
people and not others. A combination of
Evoked potential tests
factors, ranging from genetics to
childhood infections, may play a role. These tests record the electrical signals
produced by your nervous system in
response to stimuli. An evoked potential
test may use visual stimuli or electrical
stimuli, in which you watch a moving
Treatment and diagnosis
visual pattern or short electrical impulses
are applied to nerves in your legs or arms.
Electrodes measure how quickly the
There are no specific tests for MS. The
information travels down your nerve
diagnosis relies on ruling out other
pathways.
conditions that might produce similar
signs and symptoms.
Treatment and drugs:
Treatments for attacks blood tests to monitor your liver
enzymes.
Corticosteroids, such as oral
prednisone and intravenous Glatiramer acetate
methylprednisolone, are prescribed to (Copaxone). This medication may
reduce nerve inflammation. Side help block your immune system's
effects may include insomnia, attack on myelin. The medication must
increased blood pressure, mood swings be injected beneath the skin. Side
and fluid retention. effects may include skin irritation at
the injection site.
Plasma exchange
(plasmapheresis). The liquid portion Dimethyl fumarate
of part of your blood (plasma) is (Tecfidera). This twice-daily oral
removed and separated from your medication can reduce relapses. Side
blood cells. The blood cells are then effects may include flushing, diarrhea,
mixed with a protein solution (albumin) nausea and lowered white blood cell
and put back into your body. Plasma count.
exchange may be used if your
Fingolimod (Gilenya). This once-
symptoms are severe and haven't
responded to steroids. daily oral medication reduces relapse
rate. You'll need to have your heart
Treatments to modify progression rate monitored for six hours after the

No therapies have shown benefit for first dose because your heartbeat may

slowing the progression of primary- be slowed. Other side effects include

progressive MS. For relapsing-remitting high blood pressure and blurred vision.

MS, certain medications can lower the


Teriflunomide (Aubagio). This
relapse rate and reduce the rate of
once-daily medication can reduce
formation of new lesions, particularly early
relapse rate. Teriflunomide can cause
in the disease course.
liver damage, hair loss and other side
The options include: effects. It is also known to be harmful
to a developing fetus.
Beta interferons. These
medications, which are injected under Natalizumab (Tysabri). This
the skin or into muscle, can reduce the medication is designed to block the
frequency and severity of relapses. movement of potentially damaging
Beta interferons can cause side effects immune cells from your bloodstream to
such as flu-like symptoms and your brain and spinal cord. The
injection-site reactions. You'll need medication increases the risk of a viral
infection of the brain called
progressive multifocal Symptoms:

leukoencephalopathy. It is generally Early Symptoms of MS


given to people who have more severe
or active MS, or who do not respond to Blurred or double vision

or can't tolerate other treatments. Thinking problems


Clumsiness or a lack of
Mitoxantrone coordination
(Novantrone). This Loss of balance
immunosuppressant drug can be
Numbness
harmful to the heart and is associated
Tingling
with development of blood cancers.
Weakness in an arm or leg
Mitoxantrone is usually used only to
treat severe, advanced MS. No two people have exactly the same
symptoms of MS.
Treatments for signs and symptoms
You may have a single symptom, and then
Physical therapy. A physical or go months or years without any others. A
occupational therapist can teach you
problem can also happen just one time, go
stretching and strengthening
away, and never return. For some people,
exercises, and show you how to use
the symptoms become worse within
devices that can make it easier to
weeks or months.
perform daily tasks.
Common Symptoms of MS
Muscle relaxants. You may
These are the most common changes to
experience painful or uncontrollable
muscle stiffness or spasms, the mind and body in someone with MS:

particularly in your legs. Muscle


Unusual sensations: People with MS
relaxants such as baclofen (Lioresal,
often say they feel a "pins and needles"
Gablofen) and tizanidine (Zanaflex)
sensation. They may also have numbness,
may help.
itching, burning, stabbing, or tearing

Medications to reduce fatigue. pains. About half of people with MS have


these uncomfortable symptoms.
Other medications. Medications Fortunately, they can be managed or
may also be prescribed for depression, treated.
pain, and bladder or bowel control
problems that are associated with MS. Bladder problems: About 8 in 10 people
have bladder problems, which can be
treated. You may need to pee often,
urgently, need to go at night, or have
trouble emptying your bladder fully. Bowel Roughly equal numbers of men and
problems, especially constipation, are also women develop primary progressive MS.
common. In other types of MS, women outnumber
men three to one.
Trouble walking: MS can cause muscle
Primary progressive MS usually
weakness or spasms, which make it harder
leads to disability earlier than relapsing-
to walk. Balance problems, numb feet, and
remitting MS (see below).
fatigue can also make walking hard.
Perhaps the most upsetting
Dizziness: It's common to feel dizzy or difference in primary progressive MS is its
lightheaded. You usually won't have poor response to treatment. So far, no
vertigo, or the feeling that the room is treatments have been shown to help,
spinning. although studies are ongoing.

Fatigue: About 8 in 10 people feel very


tired. It often comes on in the afternoon Relapsing-Remitting Multiple Sclerosis
and causes weak muscles, slowed
Most people with multiple sclerosis --
thinking, or sleepiness. It's usually not
around 90% -- have the relapsing-
related to the amount of work you do.
remitting type. Most people with this type
Some people with MS say they can feel
of MS first experience symptoms in their
tired even after a good night's sleep.
early 20s. After that, there are periodic
attacks (relapses), followed by partial or
Types: complete recovery (remissions).

Primary Progressive Multiple Sclerosis The pattern of nerves affected, severity of

In primary progressive multiple sclerosis, attacks, degree of recovery, and time

symptoms continually worsen from the between relapses all vary widely from

time of diagnosis. There are no well- person to person.

defined attacks, and there is little or no Eventually, most people with relapsing-
recovery. Between 10% and 15% of people remitting MS will enter a secondary
with MS have primary progressive MS. progressive phase of MS.

Several aspects of primary progressive MS Secondary Progressive Multiple Sclerosis


distinguish it from other types of MS:
After living with relapsing-remitting MS for
People with primary progressive MS many years, most people will develop
are usually older at the time of diagnosis -- secondary progressive MS. In this type of
an average age of 40. MS, symptoms begin a steady march,
without relapses or remissions. (In this Progressive relapsing MS is rare enough
way, secondary progressive MS is like that little is known about it. Probably
primary progressive MS.) The transition around 5% of people with multiple
typically occurs between 10 and 20 years sclerosis have this form. Progressive
after the diagnosis of relapsing-remitting relapsing MS seems similar to primary
MS. progressive MS in many ways.

It's unclear why the disease makes the What Causes Multiple Sclerosis?

transformation from relapsing-remitting to No one knows what causes multiple


secondary progressive MS. A few things sclerosis. Tantalizing clues have sparked
are known about the process: research in many areas but no definite

The older a person is at original answers. Some theories have included:

diagnosis, the shorter the time for the Geography. People in the northern
disease to become secondary U.S. develop MS more often than those in
progressive. the warmer south. Research into vitamin D
People with incomplete recovery
and sunlight as protective factors is
from initial relapses generally convert to ongoing.
secondary progressive MS sooner than Smoking. Tobacco may increase
those who recover completely. the risk slightly. But it's not the whole
The process of ongoing nerve
story.
damage changes. After the Genetics. Genes do play a role. If
transformation, there's less inflammation, an identical twin has MS, the other twin
and more slow degeneration of nerves. has a 20% to 40% chance of developing it
Secondary progressive MS is challenging as well. Siblings have a 3% to 5% chance
to treat -- and to live with. Treatments are if a brother or sister is affected.
moderately effective at best. Progression Vaccines. Extensive research has
occurs at a different rate in each person essentially ruled out vaccines as a cause
and generally leads to some disability. of MS.

Multiple sclerosis is probably an

Progressive Relapsing Multiple Sclerosis autoimmune disease. Like lupus or


rheumatoid arthritis, the body creates
Progressive relapsing multiple sclerosis is
antibodies against itself, causing damage.
the least common form of the disease.
In MS, the damage occurs in the lining, or
Relapses or attacks occur periodically.
myelin, of nerves.
However, symptoms continue and are
How Is Multiple Sclerosis Diagnosed?
progressive between relapses.
Multiple sclerosis is generally diagnosed MS can be prolonged. Studies show that
after a person has experienced because symptoms are often low-grade or
troublesome symptoms related to nerve vague, doctors may miss the diagnosis.
damage. Vision loss, weakness, and loss of
Even when symptoms are definitely
sensation are common complaints.
consistent with MS, the diagnosis still can't
The most common tests used to diagnose be made right away. This is because, by
MS are scans of the brain and spinal cord definition, multiple sclerosis is a long-term
with magnetic resonance imaging (MRI) illness. After the first symptoms, there's an
and lumbar puncture or a spinal tap. often frightening and frustrating period of
waiting until more symptoms occur and
Unfortunately, the time between the first
the diagnosis becomes clear.
appearance of symptoms and diagnosis of