eMedicine Specialties > Neurology > Inflammatory and Demyelinating Diseases

Multiple Sclerosis: Follow-up

Author: Fernando Dangond, MD, Senior Director of Medical Affairs, Neurology, EMD Serono, Inc
Contributor Information and Disclosures

Updated: Sep 11, 2009

Follow-up

Deterrence/Prevention

  • Patients with multiple sclerosis must understand that the ABCR immunomodulatory drugs are preventive, not curative. Early treatment is thus essential.
  • Patients should avoid exposure to extreme heat.
  • The impact of stress on multiple sclerosis exacerbations is thought to be minimal or noncontributory, and trauma has no demonstrated impact on the disease course.

Complications

  • Complications in patients with multiple sclerosis include the following:
    • Adverse drug reactions
    • Rare cases in which large, tumor-like demyelinating lesions necessitate brain biopsy to rule out malignancy
  • For bedridden patients, preventive measures regarding decubitus ulcers, atelectasis, pneumonia, and aspiration should be addressed.
  • Seizures are rare in MS but may occur at a higher rate than in the general population. Patients with seizures who work in conditions of high risk for self-injury (eg, operating heavy machinery) should exercise caution, taking into account specific state laws. This also pertains to driving a motor vehicle.
  • Patients with ataxia and weakness are at increased risk of falls and personal injury; the physician should recognize these patients early and provide any needed assistance.

Prognosis

  • If untreated, more than 30% of patients with multiple sclerosis will develop significant physical disability within 20-25 years from onset. This prognosis is changing for these patients with the advent of new treatments.
  • Male patients with PPMS have the worst prognosis, responding less favorably to treatment and rapidly accumulating disability. The higher incidence of spinal cord lesions in PPMS is also a factor in the rapid development of disability.
  • Less than 5-10% of patients have a clinically milder MS phenotype, in which no significant physical disability accumulates despite several decades passing since onset (sometimes in spite of multiple new lesions by MRI). Detailed examination of these patients in many instances reveals some degree of cognitive deterioration.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Treatment of presumed MS is not indicated. The neurologist should have a fairly reasonable diagnosis based on history, clinical examination, and MRI findings. Treatment based on a suspected diagnosis can lead to unnecessary emotional and financial costs and should be avoided.
  • A common misconception is that any attack of demyelination means a diagnosis of acute MS. If a patient has the first attack of demyelination, the physician should not rush to diagnose MS. Postinfectious demyelination or other diseases that mimic MS should be considered carefully. Follow-up should be performed to ascertain whether the episode was self-limited. Although therapy for CIS with immunomodulatory medications has not yet become standard practice throughout the world, recent trials suggest that early intervention may be appropriate. The McDonald diagnostic criteria are helpful in the decision to treat patients early during the course of relapsing MS.
  • Clinicians who specialize in MS commonly see patients referred for multiple, ill-defined, vague complaints who had recent head or spine MRIs in which T2 hyperintense lesions have been demonstrated.
    • Careful questioning reveals that symptoms have been stereotyped and vague or do not truly qualify as exacerbations (eg, scintillating scotomas in a patient who also admits to concomitant migraines; symptoms consistent with carpal tunnel syndrome).
    • A history of meningoencephalitis during childhood occasionally emerges and an explanation for the lesions may become obvious.
  • A third common problem is the presence of small T2 hyperintensities, typically referred to as unidentified bright objects (UBOs) by neuroradiologists.
    • These nonspecific lesions are relatively common in the general adult population, and clinical correlation (ie, a high degree of suspicion based on clinical evidence) becomes important in the diagnosis.
    • The neurologist seeking to confirm MS should look for sites of involvement that are rare for UBOs but frequent for MS (eg, corpus callosum or throughout the spinal cord).

Special Concerns

  • For the patient with multiple sclerosis who wants to become pregnant, disease-modifying drugs should be discontinued.
  • If the patient becomes pregnant during treatment, the drug should be discontinued immediately.
  • The treatment can be resumed a few weeks after delivery or after the patient finishes her period of lactation.
 


More on Multiple Sclerosis

Overview: Multiple Sclerosis
Differential Diagnoses & Workup: Multiple Sclerosis
Treatment & Medication: Multiple Sclerosis
Follow-up: Multiple Sclerosis
Multimedia: Multiple Sclerosis
References
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Further Reading

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Keywords

multiple sclerosis, MS, multiple sclerosis treatment, multiple sclerosis symptoms, MS symptoms, MS treatment, multiple sclerosis diagnosis, myelin, inflammatory disease of central nervous system, demyelinating disease, sclerosis in plaques, CNS disease, disseminated sclerosis, focal sclerosis, insular sclerosis, elevated immunoglobulin G, interleukin-12, IL-12, B7-1, relapsing remitting MS, RRMS

secondary progressive MS, SPMS, primary progressive MS, PPMS, relapsing progressive MS, RPMS, brain atrophy, spinal cord atrophy, short-term memory problems, difficulty executing sequential tasks, visuospatial disturbances, benign MS, cognitive dysfunction, mental slowing, cognitive slowing, lack of sleep, optic nerve dysfunction, Uhthoff phenomenon, Marburg variant of MS

necrotizing myelopathy, neuromyelitis optica, Devic disease, acute disseminated encephalomyelitis, ADEM, Schilder disease, Baló concentric sclerosis, ataxia, hemiparesis, paraparesis, depression, bipolar disorder, dementia, optic neuritis, orbital pain, patchy loss of vision, cecocentral scotoma, afferent pupillary defect

facial palsies, trigeminal neuralgia, facial myokymia, nystagmus, internuclear ophthalmoplegia, painful limb syndromes, central vertigo, diplopia, dysarthria, pseudobulbar affect, social disinhibition, chronic inflammatory demyelinating polyradiculopathy, CIDP, conversion reactions, la belle indifference, urinary retention

urinary incontinence, sexual dysfunction, Kurtzke Expanded Disability Status Scale, immune dysfunction, HLA-DR2 allele, pro-demyelinative tumor necrosis factor alpha molecule, pro-inflammatory interferon gamma, proinflammatory interferon gamma

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Contributor Information and Disclosures

Author

Fernando Dangond, MD, Senior Director of Medical Affairs, Neurology, EMD Serono, Inc
Fernando Dangond, MD is a member of the following medical societies: American Academy of Neurology and American Medical Association
Disclosure: EMD Serono, Inc. Salary Employment

Medical Editor

William J Nowack, MD, Associate Professor, Epilepsy Center, Department of Neurology, University of Kansas Medical Center
William J Nowack, MD is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, American Medical Electroencephalographic Association, American Medical Informatics Association, and Biomedical Engineering Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

B Mark Keegan, MD, FRCPC, Assistant Professor of Neurology, College of Medicine, Mayo Clinic; Master's Faculty, Mayo Graduate School; Consultant, Department of Neurology, Mayo Clinic, Rochester
B Mark Keegan, MD, FRCPC is a member of the following medical societies: American Academy of Neurology, American Medical Association, and Minnesota Medical Association
Disclosure: Nothing to disclose.

 
 
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