MULTIPLE SCLEROSIS PATHOLOGY

 “DISSEMINATED SCLEROSIS”  IMMUNE RESPONSE RESULTS IN RECURRENT

 “ENCEPHALOMYELITIS DISSEMINATA” INFLAMMATORY REACTIONS → LEADING TO
 CHRONIC DEBILITATING PROGRESSIVE DISEASE WITH PERIPHERAL VASCULITIS.
PERIODS OF REMISSION AND EXACERBATION.  VASCULITIS
 CHARACTERIZED BY RANDOMLY SCATTERED PATCHES o BRAKDOWN BBB → ALLOWING MIGRATION OF
OF DEMYELINATION IN THE BRAINSTEM, CEREBRUM, LYMPHOCYTES INTO THE CNS
CEREBELLUM AND SPINAL CORD. ↓
o ONCE IN THE CNS LYMPHOCYTES SECRETE IgG
MULTIPLE SCLEROSIS
ANTIBODIES W/C ↑ DURING EXACERBATIONS
 JEAN MARIE CHARCOT (1868) OF THE DISEASE PROCESS.
 NAME REFERS TO “SCARS = SCLEROSES” → PLAQUES ↓
OR LESIONS IN THE WHITE MATTER OF THE BRAIN AND o MACROPHAGES ENTER THE MYELIN SHEATH
SPINAL CORD, W/C IS MAINLY COMPOSED OF MYELIN. AND REMOVE DEGENERATING MYELIN
 THE BODY’S OWN IMMUNE SYSTEM ATTACKS AND ↓
DAMAGES THE MYLEIN SHEATH o FORMING PATCHY AREAS OF DEMYLELINATION
o WHEN MYELIN IS LOST, THE AXONS CAN NO → AREAS OF MISSING MYELIN = PLAQUES
LONGER EFFECTIVELY CONDUCT SIGNALS ↓
o AFFECTS THE ABILITY OF NERVE CELLS IN THE o PLAQUES → REDUCE SUPPORT OF THE NERVE
BRIAN AND SPINAL CORD TO COMMUNICATE CELLS → HINDERS NM CONDUCTION.
WITH EARCH OTHER.  ACUTE STAGE OF MS → INFLAMM
 ETIOLOGY → UNKNOWN EDEMA AROUND PLAQUE SITES IS
 COMMON IN WOMEN 20-40 NOTED
 CHRONIC STAGE → GLIOSIS OF AXONS
THEORIES
OCCUR = PERMANENT DISABILITY.
 AUTO-IMMUNE RESPONSE  MANIFESTATION OCCUR
 ENVIRONMENTAL FACTORS INTERMITTENTLY.
o ↑ INCIDENCE IN TEMPERATE TO COOL  AREAS OF PLAQUE DEVELOPMENT
CLIMATES  CEREBELLUM → POSTURE,
o COUNTRIES WAY NORTH OF THE EQUATOR BALANCE, COORDINATION
 VIT. D DEICIENCY  MEDULLA → RESPIRATION
 GENETICS AND CIRCULATION
o PRESENCE OF SPECIFIC CLUSTER OF  CEREBRUM → MOVEMENT
(HAPLOTYPE) OF HUMAN LEUKOCYTE ANTIGEN SENSORY, LANGUAGE,
(HLA) LEARNING, MEMORY.
o A GROUP OF GENES IN CHROMOSOME 6 THAT
SERVES AS MAJOR HISTOCOMPATIBILITY AREAS OF PLAQUE FORMATION
COMPLEX (MHC) IN HUMANS
o PROMOTES SUSCEPTIBILITY TO VIRUS THAT  CORTICOSPINAL SYNDROME
TRIGGERS AN AUTOIMMUNE RESPONSE o CORTICOSPINAL TRACTS ARE AFFECTED
ACTIVATED IN MS o SYMMETRIC MUSCULAR
 INFECTION BY A SLOW LATENT VIRUS WEAKNESS/STIFFNESS, SPASTIC PARALYSIS,
 BLOOD-BRAIN BARRIER BREAKDOWN BOWEL AND BLADDER INCONTINENCE
o CAPILLARY SYSTEM THAT SHOULD PREVENT o PARESTHESIA
ENTRANCE OF T CELLS INTO THE NERVOUS  CEREBRAL SYNDROME
SYSTEM o CELLS OF THE CEREBRAL HEMISPHERES ARE
o BBB IS UNPERMEABLE TO THESE TYPE OF AFFECTED
CELLS UNLESS TRIGGERED BY INFECTION OR o OPTIC NEURITIS, IMPAIRED VISION,
INTELLECTUAL AND EMOTIONAL
VIRUS W/C ↓ THE INTEGRITY OF TIGHT
DETERIORATION.
JUNCTIONS FORMING THE BARRIER.
 BRAINSTEM SYNDROME
o WHEN BBB REGAINS ITS INTEGRITY → T CELLS
o PRIMARILY AFFECTS CN 3 AND 12
ARE TRAPPED INSIDE THE BRAIN
o CAUSING DYSFUNCTION OF THE EOM AND
 T HELPER CELLS
INNERVATIONSS TO THE MUSCLES FOR
o TH1 & TH7
SPEECH.
o IN PERSON W/ MS THESE CELLS RECOGNIZED
HEALTHY PART OF CNS AS FOREIGN THUS
ATTACK THEM → TRIGGER AN INFLAMMATION
PROCESSS → STIMULATES CYTOKINES AND
ANTIBOSIES.
o OTHER TYPE OF IMMUNE CELLS → B CELLS
TYPES OF MULTIPLE SCLEROSIS  COGNITIVE DYSFUNCTION
o ↓ CONCENTRATION, SHORT TERM MEMORY
 BENIGN MULTIPLE SCLEROSIS LOSS
o MILD INFREQUENT SENSORY EXACERBATIONS o DIFFICULTY FINIDNIG WORD AND LEARNING
W/FULL RECOVERY. NEW INFO.
 RELAPSING REMITTING MULTIPLE SCLEROSIS o EMOTIONAL INSTABILITY/LABILITY
o EPISODES OF EXACERBATION AND  APATHY
REMISSIONS DURING W/ NOT ALL SYMPTOMS  EUPHORIA DURING REMISSIONS
RESOLVE COMPLETELY  REACTIVE DEPRESSION
o MAY BE LEFT W/ PERMANENT DISABILITY W/  SUDDEN WEEPING,FORCED LAUGHTER
MAY VARY IN SEVERITY.  CONCOMITANT OF
o RELAPSES ARE OFTEN MORE SEVERE. PSEUDOBULBAR PALSY
 PRIMARY PROGRESSIVE  CORTICOBULBAR PATHWAYS
o NO HX OF RELAPSE OF EMOTIONAL CONTROL ARE
o BEGINS W/ SLOW PROGRESSIVE OF AFFECTED
NEUROLOGICAL DEFICITS o SHORT ATTENTION SPAN
o PROBLEMS APPEAR AND GRADUALLY  CRANIAL NERVE DYSFUNCTION
WORSENS OVERTIME o CHANGES IN VISUAL FIELDS
o COMMON PROBLEMS  BLIND SPOTS (SCOTOMA)
 SPASTIC PARAPARESIS  BLIND CENTRAL VISION (CENTRAL
 CEREBELLAR ATAXIA SCOTOMA).
 URINARY INCONTINENCE o OPTIC NEURITIS
 SECONDARY CHRONIC PROGRESSIVE  WITH PAPILLEDEMA
o CONDITION OF PATIENT WITH  AFFECTED PUPIL DOES NOT
RELAPSING/REMITTING DISEASE BEGINS TO CONSTRICT
GRADUALLY WORSEN OVERTIME WITH o OPTHALMOPLEGIA WITH DIPLOPIA
RESULTING ACCUMULATION OF NEUROLOGIC  DUE TO INVOLVEMENT OF BS TRACTS
SIGNS AND SYMPTOMS CONNECTING CN 3, 4, 6
o RELAPSES BECOMES MORE SEVERE AND o DYPHAGIA
REMISSIONS ARE LESS COMPLETE, SHORTER o FACIAL WEAKNESS, NUMBNESS, PARESTHESIA
IN DURATION AND EVENTUALLY NON-EXISTENT.  UNILATERAL
o MS → STEADILYT PROGRESSIVE o RESEMBLING TRIGEMINAL NEURALGIA
o HEMIFACIAL PALSY/SPASM
2 MAJOR COURSES OF MS  MOTOR DYSFUNCTION
o ABNORMAL GAIT/ GAIT DISTURBANCES
 EXACERBATING-REMITTING
o PARALYSIS/PARESIS
o PATIENT HAS EPISODES OF NEUROLOGIC
o SPASTICITY
DYSFUNCTION (EXA) FROM W/C HE/SHE
o WEAKNESS
RECOVERS (REM)
o ↑DTR
o RECOVERY FROM EACH EXACERBATIONS IS
o (+) BABINSKI, (+) CLONUS
INCOMPLETE CAUSING A STEPWISE DECLINE IN
o DIMINISHED/ABSENT SUPERFICIAL REFLEXES
FXN W/ EACH EXACERBATIONS.
 SENSORY DYSFUNCTION
 CHRONIC PROGRESSIVE
o STEADY DECLINE IN NEURO FXN THAT CAN o ↓ PROPRIOCEPTION
OCCUR OVER SEVERAL YEARS o ↓ TEMPERATURE PERCEPTION
o PARESTHESIAS
CLINICAL MANIFESTATIONS o LHERMITT’S SIGN
 ELECTRIC SHOCK SENSATION ON
 CEREBELLAR DYSFUNCTION FLEXION OF THE NECK
o ATAXIA, DYSARTHRIA, INCOORDINATION,  AUTONOMIC DYSFUNCTION
TREMOR, VERTIGO o BOWEL AND BLADDER CONTROL
o CHARCOT’S TRIAD o CONSTIPATION
 NYSTAGMUS o URINARY/ FECAL INCONTINENCE
 INTENTION TREMORS o URINARY RETENTION
 → TREMORS EXHIBITIED OR o NOCTURIA, POLYURIA
INTENSIFIED WHEN  SEXUAL DYSFUNCTION
ATTEMPTING COORDINATED o ↓ LIBIDO
MOVEMENTS.
 SCANNING SPEECH
 → SLOW ENUNCIATION W/
TENDENCY TO HESITATE AT
THE BEGINNING OF A WORD
OR SYLLABLE.
DIAGNOSTICS  INHIBITS ANTIGEN-SPECIFIC T CELL
ACTIVATION
 CT SCAN/MRI (MOST SENSITIVE)
o PLAQUES AND DEMYELINATION IN THE CNS  (COMPAXONE)
 EMG GLATIRAMER ACETATE (SQ
o SLOWING NERVE CONDUCTION EVERYDAY)
 REVIEW OF HX / SYMTOMATOLOGY  REBIF (SQ 3X A WEEK)
 PAPILLEDEMA SEEN DURING OPTHALMIC EXAM  BACLOFEN (LIORESAL)
 ANGIOGRAPHY o GABA ANTAGONIST
 CSF ANALYSIS o DOC FOR SPASM
o ↑WBC, ↑ CHON, ↑ IgG (>13%) o P.O / INTRATHECAL
o ↑ OLIGOCLONAL BANDS OF IgG  DIAZEPAM, DANTROLENE NA → SPASM
 INDICATES IgG SYNTHESIS W/IN BBB
 IgG CORELATES W/ DSE. SEVERITY
 AMANTADINE (SYMMETREL) → FATIGUE
 SEEN IN 90 % OF MS CLINETS  FLOUXETINE (PROZAC) → FATIGUE, DEPRESSION
 ABSENCE DOES NOT R/O MS  PORPANOLOL (INDERAL → ATAXIA
 NSAID’s → PAIN
PHARMACOLOGIC
 ASCORBIC ACID → ACIDIFY URINE
 STEROIDS
MANAGEMENT
o STEROIDS AND ACTH TO CONTROL
EXACERBATIONS  PLASMAPHERESIS
o STEROIDS → MODULATE THE IMMUNE  SUPPORTIVE
RESPONSE o EYE PATCH → DIPLOPIA
 IV METHYLPREDNISONE (HIGH o DIET → ↑ FIBER
DOSES) o PHYSICAL THERAPY
 ORAL PREDNISONE (TAPERED o FORCE FLUID
DOSES) o AVOID HOT BATHS → ↑ WEAKNESS
 REHABILITATION
o WOF MOOD CHANGES, FEB ALTERATIONS
o REFER TO PT, OT, ST
 IMMUNOSUPPREIVE AGENTS
o SLOW THE PROGRESSION OF THE DISEASE NURSING INTERVENTION
AND REDUCE FREQUENCY OF ATTACKS
FOR SOME PATIENTS  FREQ. REST PERIOD
 AVOID HOT BATHS
o TX OF SECONDARY PROGRESSIVE MS
 USE OF ASSITIVE DEVICES
 CYCLOPHOSPHAMIDE  ASSIST FAMILY TO UNDERSTAND WHY THE CLIENT
 MITOXANTRONE(NOVANTRONE) SHOULD BE PERMITTED AND ENCOURAGE TO BE
 ANTINEOPLASTIC DRIG ACTIVE.
(LEUKEMIA, LYMPHOMA)  (-) FALSE HOPES
 INTERFERONS  LISTEN TO FAMILY AND PATIENTS → VENTILATE
o CLASS OF CYTOKINES WITH BROAD ANTI- FEELINGS
VIRAL EFFECTS  REFER TO NATIONAL MULTIPLE SLCEOSIS SOCIETY
o CHON FORMED WHEN CELLS ARE  COMPENSATE FOR PROBLEMS WITH GAIT
EXPOSED TO VIRUSES o CANE, WALKER
 COMPENSATE FOR LOSS OF SENSATION
o NON-INFECTED CELLS EXPOSED TO
o THERMOMETER
INTERFERONS ARE PROTECTED AGAINST  COMPENSATE FOR DYSPHAGIA
VIRAL INFECTION. o SMALL BITES
o INTERFERON BETA → ABC-R  ADEQ. NUTRITION
 MAIN PHARMACOLOGIC THERAPY  PREVENT DECUBITI AND CONTRACTURES
FOR MS o FREQ. TURNING
 ↓ THE FREQ.OF RELAPSE BY 30% o AROM, PROM
 ↓ APPEARANCE OF NEW LESIONS o EXERCISES
o SPLINTS
IN THE MRI BY 80 %
 75% EXPERIENCE FLU LIKE
SYMPTOMS → NSAID’s
 INHIBITS T CELL PROLIFERATION
 AVONEX (IM 1 X WK)
 BETASERON (SQ EVERY
OTHER DAY)