Multiple sclerosis in childhood and adolescence: clinical features and management

Pediatric multiple sclerosis: developments in timely diagnosis and prognostication

INTRODUCTION

Pediatric-onset (PO) multiple sclerosis (MS) accounts for about 2-10% of the total MS cases. Recently, a greater attention has been given to POMS, with substantial improvements in the understanding of its pathophysiology, in the diagnostic work-up and in the identification of reliable prognosticators associated with long-term disability in these patients.

AREAS COVERED

This review summarizes the most recent updates regarding the pathophysiology of POMS, the current diagnostic criteria and the clinical, neuroradiological and laboratoristic markers that have been associated with disease progression (i.e. occurrence of a second clinical attack at disease onset and accumulation of disability in definite MS).

EXPERT OPINION

The study of POMS, where the clinical onset is closer to the biological onset of MS, may contribute to better understand how the different pathological processes impact brain maturation and contribute to disease progression, but also how brain plasticity may counterbalance structural damage accumulation. Although rare, POMS is a severe disease, characterized by a prominent clinical and radiological activity at disease onset and by the accumulation of physical and cognitive disability at a younger age compared to the adult counterpart, with significant detrimental consequences at long-term. Early and accurate diagnosis, together with early treatment, is highly warranted.

Gait Variability, Not Walking Speed, Is Related to Cognition in Adolescents With Multiple Sclerosis

Gait variability is associated with cognitive performance in people with central neurologic damage illnesses, which includes multiple sclerosis. However, presently, there have been no data available as to whether this association exists in adolescents with multiple sclerosis. Therefore, our objective was to investigate the association between gait variability and cognition in adolescents with multiple sclerosis encompassing 48 recently diagnosed adolescents with multiple sclerosis (26 girls; 22 boys), average age of 16.0 years (SD = 2.2), and an Expanded Disability Status Scale (EDSS) score of 1.6 (SD = 1.3). Walking speed and gait variability expressed by the coefficient of variation of the mean step time was studied using an electronic walkway. A computerized cognitive battery of tests evaluated cognition. Cognitive outcome measurements included verbal and nonverbal memory, executive function, visual spatial processing, verbal function, attention, information processing speed, and motor skills. Mean walking speed was 76.9 cm/s (SD = 57.6); mean step time variability was 3.5 (SD = 1.3) and the global cognitive score was 93.9 (SD = 12.5). According to linear regression analysis, a significant association was found between step time variability, cognitive subdomains of attention, and information processing speed. After incorporating walking speed into the model, the association remained significant. Increased gait variability, not walking speed, is suggested as a clinical marker of cognitive performance in minimally disabled adolescents with multiple sclerosis.

Brain Lesion Load and Anatomic Distribution in Patients With Juvenile Clinically Isolated Syndrome Predicts Rapidly Advanced to Multiple Sclerosis

The aim was to assess brain lesion load and anatomical distribution in patients with juvenile clinically isolated syndrome and define magnetic resonance imaging (MRI) variables associated with rapidly advancing to multiple sclerosis. Patients were followed for one year after disease onset. Patients who experienced a second relapse were defined as those who rapidly advanced to multiple sclerosis. In all, 46 juvenile patients with a clinical presentation suggestive of multiple sclerosis were evaluated; 21 with gadolinium-enhancing lesions on initial brain MRI were excluded as they had already fulfilled the diagnosis criteria for multiple sclerosis. A total of 25 patients, 10 males and 15 females (mean ± SE age at onset 15.6 ± 0.6 years), met the definition of clinically isolated syndrome. The presence of a corpus callosum lesion at onset significantly differentiated between sustained clinically isolated syndrome and patients who rapidly advanced to multiple sclerosis.

The influence and impact of ageing and immunosenescence (ISC) on adaptive immunity during multiple sclerosis (MS) and the animal counterpart experimental autoimmune encephalomyelitis (EAE)

The human ageing process encompasses mechanisms that effect a decline in homeostasis with increased susceptibility to disease and the development of chronic life-threatening illness. Increasing age affects the immune system which undergoes a progressive loss of efficiency, termed immunosenescence (ISC), to impact on quantitative and functional aspects of innate and adaptive immunity. The human demyelinating disease multiple sclerosis (MS) and the corresponding animal model experimental autoimmune encephalomyelitis (EAE) are strongly governed by immunological events that primarily involve the adaptive arm of the immune response. MS and EAE are frequently characterised by a chronic pathology and a protracted disease course which thereby creates the potential for exposure to the inherent, on-going effects and consequences of ISC. Collective evidence is presented to confirm the occurrence of established and unendorsed biological markers of ISC during the development of both diseases. Moreover, results are discussed from studies during the course of MS and EAE that reveal a premature upregulation of ISC-related biomarkers which indicates untimely alterations to the adaptive immune system. The effects of ISC and a prematurely aged immune system on autoimmune-associated neurodegenerative conditions such as MS and EAE are largely unknown but current evaluation of data justifies and encourages further investigation.

Gait Characteristics in Adolescents With Multiple Sclerosis

BACKGROUND

Multiple sclerosis is a progressive autoimmune disease of the central nervous system. A presentation of multiple sclerosis before age18 years has traditionally been thought to be rare. However, during the past decade, more cases have been reported.

PATIENT DESCRIPTION

We examined gait characteristics in 24 adolescents with multiple sclerosis (12 girls, 12 boys). Mean disease duration was 20.4 (S.D. = 24.9) months and mean age was 15.5 (S.D. = 1.1) years. The mean expanded disability status scale score was 1.7 (S.D. = 0.7) indicating minimal disability. Outcomes were compared with gait and the gait variability index value of healthy age-matched adolescents.

RESULTS

Adolescents with multiple sclerosis walked slower with a wider base of support compared with age-matched healthy control subjects. Moreover, the gait variability index was lower in the multiple sclerosis group compared with the values in the healthy adolescents: 85.4 (S.D. = 8.1) versus 96.5 (S.D. = 7.4).

CONCLUSIONS

We present gait parameters of adolescents with multiple sclerosis. From a clinical standpoint, our data could improve management of walking dysfunction in this relatively young population.

Cognitive dysfunction in pediatric multiple sclerosis

Cognitive and neuropsychological impairments are well documented in adult multiple sclerosis (MS). Research has only recently focused on cognitive disabilities in pediatric cases, highlighting some differences between pediatric and adult cases. Impairments in several functions have been reported in children, particularly in relation to attention, processing speed, visual-motor skills, and language. Language seems to be particularly vulnerable in pediatric MS, unlike in adults in whom it is usually preserved. Deficits in executive functions, which are considered MS-specific in adults, have been inconsistently reported in children. In children, as compared to adults, the relationship between cognitive dysfunctions and the two other main symptoms of MS, fatigue and psychiatric disorders, was poorly explored. Furthermore, data on the correlations of cognitive impairments with clinical and neuroimaging features are scarce in children, and the results are often incongruent; interestingly, involvement of corpus callosum and reduced thalamic volume differentiated patients identified as having a cognitive impairment from those without a cognitive impairment. Further studies about pediatric MS are needed in order to better understand the impact of the disease on brain development and the resulting effect on cognitive functions, particularly with respect to different therapeutic strategies.

Childhood–juvenile multiple sclerosis: clinical characteristics and treatment

The characteristics of multiple sclerosis with onset during childhood or adolescence are presented in this review. The clinical findings are similar to those of the adult form, but some aspects are peculiar: the high female to male ratio, occurrence of hyperacute forms, occurrence of encephalopatic symptoms and high relapse rate. The evolution is relapsing-progressive in most cases. Mild and severe disability are reached after a longer interval than in the adult form but, in spite of this, at a given age disability is higher. A high relapse rate, short interval between first and second attack and high disability after the first year are negative prognostic factors. Magnetic resonance imaging and cerebrospinal fluid data are discussed, with particular reference to differential diagnosis from acute disseminated encephalomyelitis. Currently, there are no controlled trials concerning subjects aged under 16 years. Some observations demonstrate that immunomodulatory drugs are well tolerated and have a beneficial effect, reducing the relapse rate and progression of the disease.

Treatment of early-onset multiple sclerosis with intramuscular interferonbeta-1a: long-term results

The objective was to evaluate the safety, tolerability and effectiveness of intramuscular (IM) interferon beta-1a (IFNbeta-1a; Avonex, Biogen) 30 mg once a week in patients with onset of symptoms of multiple sclerosis (MS) in childhood or adolescence. Patients with a diagnosis of definite MS according to McDonald's criteria, relapsing course according to Lublin's criteria, onset of symptoms of MS before 16 years of age, and who had received IM IFNbeta-1a therapy before 16 years of age were eligible for the study if they had a pretreatment and treatment duration of at least 6 months. Clinical and laboratory evaluations were performed every 3 months. A total of 52 patients were identified as receiving treatment with IM IFNbeta-1a 30 mg once a week before 16 years of age. Mean age at onset of symptoms of MS was 11.7+/-2.7 years, mean disease duration was 25.9+/-30.3 months, mean annualised relapse rate was 1.9+/-1.1 and mean Expanded Disability Status Scale (EDSS) score was 1.5+/-1.1. After a mean (+/-SD) treatment duration of 42.9+/-19.9 months, annualised relapse rate decreased to 0.4+/-0.5. Final EDSS score was 1.3+/-1.1. Adverse events were recorded for 35 (67%) patients (flulike syndrome, 33%; headache, 29%; myalgia, 21%; fever, 11%; fatigue, 6%; nausea and vomiting, 6%; and skin reaction, 4%); most were transient. IM IFNbeta-1a was effective and well tolerated in these paediatric patients with MS.

Intermediate uveitis in childhood preceding the diagnosis of multiple sclerosis: a 13-year follow-up

PURPOSE

An association between multiple sclerosis during childhood and uveitis is exceptionally rare. This is a report of a female patient who presented at the age of 8 years with bilateral intermediate uveitis and whose final diagnosis of multiple sclerosis was made at age 21 years.

DESIGN

Case report.

METHOD

Retrospective chart review of a 13-year follow-up history.

RESULTS

Over 10 years our patient was treated systemically and underwent bilateral vitrectomy to reduce permanent side effects. Owing to good visual function and low inflammatory signs, systemic therapy was stopped. Multiple sclerosis was diagnosed at the age of 21, after a 13-year history of uveitis and after 3 years without medication.

CONCLUSIONS

In the constellation of uveitis in childhood and later diagnosis of multiple sclerosis, the outlined therapy provided good functional results. Moreover, it may have delayed the manifestation of the underlying disease for 13 years.