1
|
Pelletier J, Sugar D, Koyfman A, Long B. Multiple Sclerosis: An Emergency Medicine-Focused Narrative Review. J Emerg Med 2024; 66:e441-e456. [PMID: 38472027 DOI: 10.1016/j.jemermed.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/15/2023] [Accepted: 12/11/2023] [Indexed: 03/14/2024]
Abstract
BACKGROUND Multiple sclerosis (MS) is a rare but serious condition associated with significant morbidity. OBJECTIVE This review provides a focused assessment of MS for emergency clinicians, including the presentation, evaluation, and emergency department (ED) management based on current evidence. DISCUSSION MS is an autoimmune disorder targeting the central nervous system (CNS), characterized by clinical relapses and radiological lesions disseminated in time and location. Patients with MS most commonly present with long tract signs (e.g., myelopathy, asymmetric spastic paraplegia, urinary dysfunction, Lhermitte's sign), optic neuritis, or brainstem syndromes (bilateral internuclear ophthalmoplegia). Cortical syndromes or multifocal presentations are less common. Radiologically isolated syndrome and clinically isolated syndrome (CIS) may or may not progress to chronic forms of MS, including relapsing remitting MS, primary progressive MS, and secondary progressive MS. The foundation of outpatient management involves disease-modifying therapy, which is typically initiated with the first signs of disease onset. Management of CIS and acute flares of MS in the ED includes corticosteroid therapy, ideally after diagnostic testing with imaging and lumbar puncture for cerebrospinal fluid analysis. Emergency clinicians should evaluate whether patients with MS are presenting with new-onset debilitating neurological symptoms to avoid unnecessary testing and admissions, but failure to appropriately diagnose CIS or MS flare is associated with increased morbidity. CONCLUSIONS An understanding of MS can assist emergency clinicians in better diagnosing and managing this neurologically devastating disease.
Collapse
Affiliation(s)
- Jessica Pelletier
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Davis Sugar
- Department of Neurology, Virginia Tech Carilion, Roanoke, Virginia
| | - Alex Koyfman
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas
| | - Brit Long
- SAUSHEC (San Antonio Uniformed Services Health Education Consortium), Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| |
Collapse
|
2
|
Ingrasci G, Tornes L, Brown A, Delgado S, Hernandez J, Yap QV, Yosipovitch G. Chronic pruritus in multiple sclerosis and clinical correlates. J Eur Acad Dermatol Venereol 2023; 37:154-159. [PMID: 36017740 DOI: 10.1111/jdv.18561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/18/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND To date, little is known about the prevalence of itch in multiple sclerosis (MS) and its characteristics. OBJECTIVES In this cross-sectional study, we assessed the prevalence, intensity and characteristics of chronic pruritus in MS patients and its effect on quality-of-life and association with MS symptoms, clinical signs, comorbidities and MRI findings. METHODS MS patients presenting to an outpatient neurology clinic were asked about their current symptoms. Those who experienced chronic pruritus were administered the Standardized Itch Questionnaire and Itch Quality of Life forms. All patients' medical records were reviewed. Patients with any medical conditions associated with chronic itch were excluded. RESULTS Seventy-seven total MS patients were included, and 27 (35%) reported pruritus. The average itch NRS severity was 5.42 (range 0-10). The most affected body parts were the extremities, face or scalp, and trunk. Itch was characterized as acute (74%), paroxysmal (59%) and tingling (55%). Heat (52%) was the most common aggravating factor, while cold temperatures had no effect. Compared with MS patients without itch, itch patients reported more fatigue (77% vs 44%, p = 0.004), heat sensitivity (48% vs 20%, p = 0.0177), cognitive impairment (62% vs 26%, p = 0.0029) and depression or anxiety (48% vs 16%, p = 0.0063). Additionally, itch patients had more T2 hyperintensities in the posterior cervical cord and anterior pons/ventromedial medulla (74.1% vs 46.0%, p = 0.018 and 29.6% vs 8.0%, p = 0.020, respectively). Finally, T2 hyperintensities in the anterior pons/ventromedial medulla were strongly associated with itch localized to the face or scalp (OR 11.3, 95% CI 1.6-78.6, p = 0.025). CONCLUSION MS patients experience paroxysmal neuropathic pruritus that is most frequently localized to the extremities, face or scalp. Patients with itch were more likely to have MS-related comorbidities and demyelinating lesions in the spinal cord or brainstem.
Collapse
Affiliation(s)
- Giuseppe Ingrasci
- Miami Itch Center, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Leticia Tornes
- Multiple Sclerosis Center of Excellence, Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Andrew Brown
- Multiple Sclerosis Center of Excellence, Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Silvia Delgado
- Multiple Sclerosis Center of Excellence, Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jeffrey Hernandez
- Multiple Sclerosis Center of Excellence, Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Qai Ven Yap
- Department of Biostatistics, Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Gil Yosipovitch
- Miami Itch Center, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| |
Collapse
|
3
|
Movement Disorders in Multiple Sclerosis: An Update. Tremor Other Hyperkinet Mov (N Y) 2022; 12:14. [PMID: 35601204 PMCID: PMC9075048 DOI: 10.5334/tohm.671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 04/13/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Multiple sclerosis (MS), a subset of chronic primary inflammatory demyelinating disorders of the central nervous system, is closely associated with various movement disorders. These disorders may be due to MS pathophysiology or be coincidental. This review describes the full spectrum of movement disorders in MS with their possible mechanistic pathways and therapeutic modalities. Methods: The authors conducted a narrative literature review by searching for ‘multiple sclerosis’ and the specific movement disorder on PubMed until October 2021. Relevant articles were screened, selected, and included in the review according to groups of movement disorders. Results: The most prevalent movement disorders described in MS include restless leg syndrome, tremor, ataxia, parkinsonism, paroxysmal dyskinesias, chorea and ballism, facial myokymia, including hemifacial spasm and spastic paretic hemifacial contracture, tics, and tourettism. The anatomical basis of some of these disorders is poorly understood; however, the link between them and MS is supported by clinical and neuroimaging evidence. Treatment options are disorder-specific and often multidisciplinary, including pharmacological, surgical, and physical therapies. Discussion: Movements disorders in MS involve multiple pathophysiological processes and anatomical pathways. Since these disorders can be the presenting symptoms, they may aid in early diagnosis and managing the patient, including monitoring disease progression. Treatment of these disorders is a challenge. Further work needs to be done to understand the prevalence and the pathophysiological mechanisms responsible for movement disorders in MS.
Collapse
|
4
|
Ramo-Tello C, Blanco Y, Brieva L, Casanova B, Martínez-Cáceres E, Ontaneda D, Ramió-Torrentá L, Rovira À. Recommendations for the Diagnosis and Treatment of Multiple Sclerosis Relapses. J Pers Med 2021; 12:jpm12010006. [PMID: 35055321 PMCID: PMC8780774 DOI: 10.3390/jpm12010006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/10/2021] [Accepted: 12/16/2021] [Indexed: 11/16/2022] Open
Abstract
Minimizing the risk of relapse is essential in multiple sclerosis (MS). As none of the treatments currently available are capable of completely preventing relapses, treatment of these episodes remains a cornerstone of MS care. The objective of this manuscript is to reduce uncertainty and improve quality of care of this neurological process. This article addresses definitions of key concepts, recommendations for clinical examination, classification criteria, magnetic resonance imaging, biomarkers, and specific therapeutic counsels including special populations such as pregnant and breastfeeding women, and children. An algorithm for treating MS relapses is also provided.
Collapse
Affiliation(s)
- Cristina Ramo-Tello
- Multiple Sclerosis and Clinical Neuroimmunology Unit, Germans Trias University Hospital, 08916 Badalona, Spain
- Correspondence:
| | - Yolanda Blanco
- Multiple Sclerosis Unit, Clínic Hospital, 08036 Barcelona, Spain;
| | - Luis Brieva
- Multiple Sclerosis Unit, IRBLLEIDA. Arnau de Vilanova Hospital, 25198 Lleida, Spain;
| | - Bonaventura Casanova
- Multiple Sclerosis and Clinical Neuroimmunology Unit, La Fe Hospital, 46026 Valencia, Spain;
| | - Eva Martínez-Cáceres
- Immunology Service, LCMN, Germans Trias University Hospital, 08916 Badalona, Spain;
| | - Daniel Ontaneda
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH 44195, USA;
| | - Lluís Ramió-Torrentá
- Multiple Sclerosis and Neuroimmunology Unit, Dr. Josep Trueta University Hospital and Santa Caterina Hospital, IDIBGI, 17004 Girona, Spain;
- Department of Medical Sciences, University of Girona, 17004 Girona, Spain
| | - Àlex Rovira
- Section of Neuroradiology, Radiology Service, Vall d’Hebron Universitary Hospital, 08035 Barcelona, Spain;
| |
Collapse
|
5
|
Freiha J, Riachi N, Chalah MA, Zoghaib R, Ayache SS, Ahdab R. Paroxysmal Symptoms in Multiple Sclerosis-A Review of the Literature. J Clin Med 2020; 9:jcm9103100. [PMID: 32992918 PMCID: PMC7600828 DOI: 10.3390/jcm9103100] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 09/17/2020] [Accepted: 09/19/2020] [Indexed: 01/08/2023] Open
Abstract
Paroxysmal symptoms are well-recognized manifestations of multiple sclerosis (MS). These are characterized by multiple, brief, sudden onset, and stereotyped episodes. They manifest as motor, sensory, visual, brainstem, and autonomic symptoms. When occurring in the setting of an established MS, the diagnosis is relatively straightforward. Conversely, the diagnosis is significantly more challenging when they occur as the initial manifestation of MS. The aim of this review is to summarize the various forms of paroxysmal symptoms reported in MS, with emphasis on the clinical features, radiological findings and treatment options.
Collapse
Affiliation(s)
- Joumana Freiha
- Gilbert and Rose Mary Chagoury School of Medicine, Lebanese American University, Byblos 4504, Lebanon; (J.F.); (N.R.); (R.Z.)
- Neurology Department, Lebanese American University Medical Center Rizk Hospital, Beirut 113288, Lebanon
| | - Naji Riachi
- Gilbert and Rose Mary Chagoury School of Medicine, Lebanese American University, Byblos 4504, Lebanon; (J.F.); (N.R.); (R.Z.)
- Neurology Department, Lebanese American University Medical Center Rizk Hospital, Beirut 113288, Lebanon
| | - Moussa A. Chalah
- Service de Physiologie-Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique–Hôpitaux de Paris, 51 avenue de Lattre de Tassigny, 94010 Créteil, France; (M.A.C.); (S.S.A.)
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est-Créteil, 94010 Créteil, France
| | - Romy Zoghaib
- Gilbert and Rose Mary Chagoury School of Medicine, Lebanese American University, Byblos 4504, Lebanon; (J.F.); (N.R.); (R.Z.)
- Neurology Department, Lebanese American University Medical Center Rizk Hospital, Beirut 113288, Lebanon
| | - Samar S. Ayache
- Service de Physiologie-Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique–Hôpitaux de Paris, 51 avenue de Lattre de Tassigny, 94010 Créteil, France; (M.A.C.); (S.S.A.)
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est-Créteil, 94010 Créteil, France
| | - Rechdi Ahdab
- Gilbert and Rose Mary Chagoury School of Medicine, Lebanese American University, Byblos 4504, Lebanon; (J.F.); (N.R.); (R.Z.)
- Neurology Department, Lebanese American University Medical Center Rizk Hospital, Beirut 113288, Lebanon
- Hamidy Medical Center, Tripoli 1300, Lebanon
- Correspondence: ; Tel.: +961-1-200800 (ext. 5126)
| |
Collapse
|
6
|
De Stefano N, Giorgio A, Tintoré M, Pia Amato M, Kappos L, Palace J, Yousry T, Rocca MA, Ciccarelli O, Enzinger C, Frederiksen J, Filippi M, Vrenken H, Rovira À. Radiologically isolated syndrome or subclinical multiple sclerosis: MAGNIMS consensus recommendations. Mult Scler 2018; 24:214-221. [DOI: 10.1177/1352458517717808] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nicola De Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Antonio Giorgio
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Mar Tintoré
- Neurology/Neuroimmunology Department, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Maria Pia Amato
- Department NEUROFARBA, Section Neurosciences, University of Florence, Florence, Italy
| | - Ludwig Kappos
- Department of Neurology, University Hospital, Kantonsspital, Basel, Switzerland
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Tarek Yousry
- Institute of Neurology, University College London, London, UK
| | - Maria A Rocca
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Olga Ciccarelli
- Institute of Neurology, University College London, London, UK
| | - Christian Enzinger
- Department of Neurology and Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | | | - Massimo Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Hugo Vrenken
- Department of Radiology and Nuclear Medicine and Department of Physics and Medical Technology, VU University Medical Center, Amsterdam, The Netherlands
| | - Àlex Rovira
- Section of Neuroradiology, Vall d’Hebron University Hospital, Barcelona, Spain
| |
Collapse
|
7
|
Zhang Y, Fan S, Han F, Xu Y. Paroxysmal Symptoms As the First Manifestation of Multiple Sclerosis Mimicking a Transient Ischemic Attack: A Report of Two Cases. Front Neurol 2017; 8:585. [PMID: 29163346 PMCID: PMC5675842 DOI: 10.3389/fneur.2017.00585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 10/18/2017] [Indexed: 01/23/2023] Open
Abstract
Paroxysmal symptoms are unusual manifestations of multiple sclerosis (MS). When presented as the first clinical manifestation, paroxysmal symptoms may easily be mistaken for transient ischemic attack (TIA). Previously, several cases of MS that reported with paroxysmal symptoms were misdiagnosed as TIA. Here, we report two additional cases, focusing on the clinical characteristics of paroxysmal symptoms in MS. Both cases had paroxysmal symptoms as their first manifestation; one presented with transient dizziness, left face numbness, and right limb weakness, and the other presented with episodic lightheadedness, blurred vision, nausea, palpitations, and tremulousness upon standing. Both of the patients' symptoms were mistaken for TIA at first, based on microembolic signals recorded by transcranial Doppler, but were later correctly diagnosed with MS based on neuroimaging and lumbar puncture. The paroxysmal symptoms responded to carbamazepine and were relieved completely after administration of intravenous methylprednisolone and interferon. Herein, we aim to summarize the differences between paroxysmal symptoms seen in MS and TIA, to facilitate a timely differential diagnosis and recommend an early appropriate treatment.
Collapse
Affiliation(s)
- Yao Zhang
- Multiple Sclerosis Center, Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Fei Han
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Xu
- Multiple Sclerosis Center, Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
8
|
Bsteh G, Ehling R, Walchhofer LM, Hegen H, Auer M, Wurth S, Di Pauli F, Wagner M, Reindl M, Deisenhammer F, Berger T. Paroxysmal and unusual symptoms as first clinical manifestation of multiple sclerosis do not indicate benign prognosis-The PaSiMS II study. PLoS One 2017; 12:e0181458. [PMID: 28749974 PMCID: PMC5547697 DOI: 10.1371/journal.pone.0181458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 07/01/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Paroxysmal (PS) and unusual symptoms (US) account for approximately 1.6% of initial manifestations of multiple sclerosis (MS) and have comparable conversion rates to clinically definite MS (CDMS) as classical bout onset symptoms (CS). However, long-term prognosis and clinical outcome of patients experiencing PS or US as first clinical manifestation are unclear. METHODS Clinical, MRI and cerebrospinal fluid data were obtained retrospectively and patients presenting with PS or US were compared to patients with CS presentation. RESULTS In a cohort of 532 relapsing onset MS patients followed for a mean period of 11.4 years (SD 3.6), 10 (1.9%) patients initially presented with PS/US. PS/US patients received disease modifying treatment (DMT) in a significantly smaller proportion immediately after the first clinical symptom (30% vs. 61.7%; p = 0.021) and during the observation period (60% vs. 83.5%; p = 0.033). In multivariate models correcting for sex, age at initial symptoms, complete remission of initial symptoms, total number of T2 and contrast-enhancing lesions, presence of oligoclonal bands and DMT exposure, PS/US were not associated with lower annualized relapse rate or lower EDSS over time. CONCLUSION In addition to a similar conversion rate to CDMS, patients presenting with PS/US at disease onset display very similar relapse and disability rates as patients with CS onset. Consequently, initial presentation with PS/US does not indicate benign or atypical MS, but requires DMT initiation based on the same criteria as in CS patients.
Collapse
Affiliation(s)
- Gabriel Bsteh
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Rainer Ehling
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neurology, Clinic for Rehabilitation Muenster, Muenster, Austria
| | | | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sebastian Wurth
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michaela Wagner
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Reindl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Thomas Berger
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| |
Collapse
|
9
|
Hawkes C, Lublin F, Giovannoni G. Editors' Welcome. Mult Scler Relat Disord 2016; 9:A1. [PMID: 27645368 DOI: 10.1016/j.msard.2016.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|