Multiple Sclerosis (MS)

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Multiple Sclerosis (MS)

Pathophysiological Phenomenon

Multiple sclerosis common abbreviated as MS is an autoimmune disorder that affects the Central Nervous System (CNS). MS results when the immune cells start invading the brain as well as the spinal cord resulting in its inflammation, tissue damage as well as neurodegeneration of white matter which is myelin (Norris, 2018). Researchers have tried to identify various causes of MS but currently there is no solid cause of this autoimmune disorder. Pathologically multiple sclerosis is defined as the presence of scars as a result of inflammation. The immune system erodes away the protective layer of the nerves referred to as the myelin, this affects the communication between the brain and other body organs.

There are four main forms of MS that have been recognized: relapsing-remitting MS, primary progressive MS, secondary progressive MS and progressive relapsing MS (Faissner, 2019). According to a studies all these forms of MS have different neuropathologists a clear indication that multiple sclerosis comes from a variety of a group of related heterogeneous diseases. Most common form of MS that tend to occur is the relapsing-remitting MS. Course of MS tends to vary between patients and is usually not predictable. Although the cause is unknown it involves a combination of genetic susceptibility in combination with non-genetic triggers including certain non-genetic triggers including environmental factors, certain viruses and also metabolism: A combination of these factors have been believed to result in an autoimmune disorder that attacks the Central Nervous System.

Incidence of Phenomenon and Impact

According to the National Institute of Health, it is estimated that MS affects roughly 400,000 people in the United States, this is double the number from when the first national research occurred in the year 1975 (Norris, 2016). Globally, National MS Society approximates more than 2.3 million people globally are living with multiple sclerosis. From the MS Discovery Forum, approximately there are 200 new cases reported every week in the United States. According to statistics, Americans living further from the equator, that is southern U.S. States have higher rates of MS as compared to those living in the northern states (Dilokthornsaku, 2016). Incidences of MS are also quite higher in people living in Norther Europe which experience cold climatic conditions. Lowest risk seems to occur among Asians, Africans and the Native Americans as well. In children, prevalence is not as high, according to a research by Nashi M. et al (2017), children make up only 4% of all MS cases. The highest number of individuals with MS are aged between 45 and 49 years an indication that age is a factor when it comes to MS.

There are various risk factors that can increase the development of MS; such as age, race, sex, family history, climate, season of birth and vitamin D. In this regard women are twice more likely to be affected in comparison to their male counterparts. The onset of the disease is often between 20 and 30 years although it can occur at any given age (Norris, 2018). Family history is also a risk factor; if one of your immediate family members has MS then it’s highly likely that one can develop the disease because of the genetic disposition associated with Multiple Sclerosis. Low exposure to sunlight leads to a deficiency in Vitamin D, which correlates with a higher risk of MS which may explain why cold areas have higher cases of MS as compared to areas with warm or cool climatic conditions. Viruses such as Epstein Bar have also been linked with MS. Patients born with MS are more frequent in winter and spring in comparison to autumn where it’s less frequent. It is argued that this could be as a result of lower vitamin D during the pregnancy period.

MS has an impact on the society both physically, financially and economically. The firs impact that can be felt especially because it is a disorder that leads to loss of mobility functions. MS can affect an individual’s way of life, this is due to high medical cost and emotional toil an affected person. MS has resulted in intangible costs, direct costs and indirect costs. Various cost estimates per person battling MS have been published indicating how high the course of treatment is. MS does not adversely affect individuals and families only but also the society at large. It is quite challenging given the amount of research and funding people invest in battling MS. The economic impact of MS on a particular country can be arrived at by identifying the number of MS patients in a country. In regards to intangible cost people with MS are dependent on care givers, since they need help in performing daily tasks. MS patients cannot carry out mundane tasks on their own due to physical and cognitive impairments. However, the data collected showcases that majority of care givers are informal, they are not certified care givers and lack proper training (Santos, 2019). A majority of the care givers are spouses or immediate family members. The time spent by informal care givers taking care of their loved ones may led up to psychological stress and anxiety. This is because they not only have to sacrifice their time; they also incur treatment cost and physical burden thus it can be deterrent to their physical health as well (Santos, 2019).

According to a research by Raggi A. et al (2016) people with MS most likely end up losing or quitting their jobs, work loss can also be cited as one of the indirect costs of MS. MS patient are easily fatigued, have difficulty in speech delivery, cognitive impairment and also experience difficulty in mobility. These symptoms are hindrance at any place of work especially one that are physically challenging. These significantly affects the labor force, whereby MS patients have to search for less tasking jobs one that require minimum physicality and low stress, however in most instances this means they have to work low paying wages. These can also affect the informal caregivers who have to forfeit their jobs and sacrifice their time to care for the patient. Studies indicate that informal caregivers experience works strain having to balance between their job and care giving.

Early mortality as a result of MS can also be identified as an indirect cost. Economic strain due to the underlying economic gain that could have been made. People who die due to MS would have contributed to the working force of the nation thus helping build on the nation’s economy (Ponzio, 2015). One of the direct costs is the medical and non-medical costs. Medical costs include a variety of things such as: inpatient and outpatient care, rehabilitation, drug prescription, physician services and other medical supplies. Direct cost of the medical cost can be estimated to range from 10,000 euros per person. Direct non-medical cost includes the modifications needed to make mobility and the stay of MS patient quite wholesome. Modifications such as mobility whereby wheelchairs will be needed and varying form of transportations, which require funds. To most families getting enough funds to ensure their loved one is completely taken care off and his needs are met may be MS not only affects an individual’s health it encompasses a far wider scope such as family and friends as well as the society.

Pathophysiology and Recent Findings

Multiple Sclerosis is among the most common forms of neurological disorders. As stated earlier, there is little knowledge as to the causes of this autoimmune disorder but with age, there has been so many research by the scientist to try and explain the results of this disease. Recent findings argue that MS may not be just a single disease but rather it is a wider spectrum involving both non-genetic trigger as well as genetic susceptibility of a person. In regards to MS pathology illustrates the conditions that correlate with the lesions. Physiology on the other hand illustrates the different actions that resulted to the development of lesions. Lesions are visible through magnetic resonance; they vary in sizes some are quite small while other are the size of a golf ball. Pathologically MS can be defined as the existence of sclerosis in the central nervous system, distributed in space. Simon Faissner explains how Physiologically MS destroys axons that are in the CNS that are shielded by the myelin (Faissner, 2019). The MS also attacks the nerve cell close to the brains gray matter. This leads to the damaging of axons in the spinal cord, optic nerve and brain. This hinders the transmission of visual information from the eye to the brain (Zephir,2018). The progression of MS in the brain results in the shrinkage of the cerebral cortex. In the case that the MS exacerbates the inflammation damages the myelin and the axons within that space. The signs and symptoms of MS also vary depending on the location of the lesion and the extent of the inflammation.

The cause of MS varies for each individual; the time span and onset of each symptom vary with the specific type. According to Faissner et al (2019)there are 4 types of MS, they derive their names from the progression of the symptoms. First is the Relapsing-remitting MS, the symptoms come in forms of attacks; this is referred to as a relapse. People can recover or return to their disabled form in between attacks. A remission is the period when the disease is inactive. A relapse may occur in a year, month or even week. A majority of the people are initially diagnosed with this form. The second form of MS is the secondary-progressive MS; this are individuals who have past experiences with relapses. However gradually symptoms begin to appear which lead to deterioration in health. Relapsing-remitting MS if left untreated can result in Secondary – progressive MS. The third form of MS is the primary-progressive MS it is associated with continuous worsening of the symptoms without any relapses. It’s also characterized with minor reliefs and it’s less common. The last form of MS and the rarest is the progressive-relapsing MS; it’s marked with steady deterioration of the symptoms and acute relapses. Some of the early of MS include: loose urine bladder, blurry and double vision, constant dizziness, muscle spasms, weakness and stiffness, numbness in the leg and face, and difficulty in balance (Dobson, 2019). In later stages of the MS various symptoms may arise such as, fatigue, cognitive dysfunction and depression. Stiffens and muscle spasms can affect the balance which hinders standing and walking. In more severe cases it may lead to paralysis. Research has found that when people with MS experience worse fatigue when they have a high fever or when they are exposed to heat (Dobson, 2019). Pain is not considered one of the first sign of MS. Pain shooting down the leg and limb spasm can be considered as symptoms of MS. Relapses in the MS can be indications of further damages in the brain. Relapses can either be mild or severe and also its duration varies.

The National Institute of Neurological Disorders and Strokes is spearheading the funding of research on the brain and nervous system. Although no definitive cause of MS has been established major strides have been made in the research of MS. In regards to treatment strides have been made to curb exacerbation of MS. New developments such as the biomarkers that have been developed to help monitor and diagnose MS. Biomarkers help in monitoring the progression of the disease. NINDS is currently monitoring various programs such as the Central Vein Sign in MS; it’s a study researching if scientist can be able to distinguish the central veins passing through brain plaques, in an attempt to distinguish MS from other neurological disorder (Absinta, 2019). Achieving this will ensure great growth and milestone in this field. Genetic research is also exploring the role genes have to play and whether it’s a potential increased risk for MS.

Medical Differential Diagnosis

There has been a misconception that attack on the CNS causing demyelination is an indication that an individual may be suffering from acute multiple sclerosis. There are various diseases that can mimic MS, this include Lyme disease, migraine, radiological isolated syndrome, spondyplopathies, neuropathy, lupus, stroke and vasculitis. These diseases have the ability to mimic MS and many a times misdiagnosis are made due to the similarity in symptoms (Thompson, 2018). Differential diagnosis entails narrowing down to the specific diagnosis. There are several differential diagnoses that are applied to the MS in order for physicians to really establish that a person is suffering from MS. The first is the spinal cord neoplasm where metastatic as well as spinal cold neoplasm including ependymomas and astrocytomas are considered. When imaging is conducted, and there is the presence of cysts as well as hemorrhage then the diagnosis of neoplasm is supported. ADEM is another differential diagnosis. ADEM is a post infectious autoimmune attack on either the brain or the spinal cord. It is characterized by onset of motor and sensory nerve dysfunction with encephalopathy which later proceeds to coma eventually resulting in death. MRI is useful in pointing out occurrence of lesions in cases of ADEM or MS. The condition can be treated with the use of steroids before biopsy is considered. Another differential diagnosis is Baló concentric sclerosis but is associated with inflammation of cerebrospinal fluid, however, it has fulminant progression when compared to multiple sclerosis (Sand, 2015).

Sarcoidosis is another differential diagnosis characterized with enhancement of white and pia matter lesions when imaging is done. Radiation myelitis which is also characterized with demyelination as well as presence of the spinal cord lesion may lead to its diagnosis as MS. Finally, another differential diagnoses are the vasculitis processes including lupus erythematosus leading to spinal lesions that may be seen as mimicking MS as there are multiple lesions that are present. Clinical history is important in helping one establish the right diagnosis. Doctors adapt various methods, to either rule out or confirm a diagnosis. This includes physical examination, medical history and neurological exam. However, the physician can suggest MRI scans and lumbar puncture. MRI which can be used adjunct to clinical diagnosis in looking at presence of lesions even when at times the scan appears normal (Norris, 2018).

Collaborative treatment options

MS has no cures however there are treatments that have been adopted that can derail the progression of the disease. Plasma exchange effective in treating flare ups, in individuals with exacerbating forms of MS. Can be used as substitute of methylprednisolone. Plasma exchange entails replace harmful Plasma from an individual’s blood with replacement Plasma, then transfusion it back (Moser, 2019). It’s important to note that this treatment has not been proven to be effective for both secondary and chronic progressive MS.

Corictosteroids methylprednisolone is injected into the vein; it is prescribed for 3-5 days. The steroids aid in suppressing the inflammation of the immune system, this ensures quick recovery from attacks. The drug does not have any long term effect on the progression of the disease. Disease – altering system vary from injected, infusion and oral treatment. Injected treatment uses Beta interferon drug which helps to regulate immune cells. This drug however has certain side effects including depression and flu-like symptoms (Auricchio, 2017). Another injection is use of Glatiramare acetate that is effective as it aids in balancing the immune cells. Its side effects are quite mild, mainly swelling in the injected area. Infusion treatment is another option whereby Natalizumab is administered once in a month and its main purpose is to prevent the immune system cells from damaging the brain and spinal cord. Although it has been deemed effective it poses serious risk for viral infection of the brain. Alemtuzumabb is also used it mainly targets to destroy the protein on the top of immune cells. It’s administered for five consecutive days and then a follow up a year later for 3 days’ infusion. These drugs may increase the autoimmune disorder therefore it’s recommended for people who have two or more inadequate MS therapies. Finally, for the oral treatment, there are various drugs that are used including Teriflunomide that reduces the swelling of activated immune cells. It is a once daily form of medication. Its side effect is nausea, hair loss and liver damage. Dirixomel fumarate is also used and it is administered twice daily (Auricchio, 2017). This drug makes the immune system less inflammatory, this helps manage the progress of the MS.

Tremors are also common in MS patients, whereby they experience uncontrollable shaking. Medication such as clonazepam can be helpful. Assistive devices, such as weight in spoons are quite helpful. Muscle spasm and weakness is also a common symptom. Mild muscle spasms are manageable through stretching and exercising it can be through yoga, water or physical therapy. It is recommended that people with MS stay physically active this reduces stiffness of the bones. Fatigue can be both cognitive and physical, however, it can be battled through engaging in daily physical activities that are mild or moderate (Feys, 2016). Also drugs such as modanfil help in battling fatigue. Occupational therapy aids people in walking while also managing your energy. Joining support groups helps in managing the stress. Support group provides an environment for one to talk with others on how they feel being a safe space. Although MS still has no cure, people are managing to live with MS through its management

References

Auricchio, F., Scavone, C., Cimmaruta, D., Di Mauro, G., Capuano, A., Sportiello, L., & Rafaniello, C. (2017). Drugs approved for the treatment of multiple sclerosis: review of their safety profile. Expert opinion on drug safety, 16(12), 1359-1371.

Absinta, M., Nair, G., Monaco, M. C. G., Maric, D., Lee, N. J., Ha, S. K., … & Reich, D. S. (2019). The “central vein sign” in inflammatory demyelination: The role of fibrillar collagen type I. Annals of neurology, 85(6), 934-942.

Dilokthornsakul, P., Valuck, R. J., Nair, K. V., Corboy, J. R., Allen, R. R., & Campbell, J. D. (2016). Multiple sclerosis prevalence in the United States commercially insured population. Neurology, 86(11), 1014-1021.

Dobson, R., & Giovannoni, G. (2019). Multiple sclerosis–a review. European journal of neurology, 26(1), 27-40.

Faissner, S., Plemel, J. R., Gold, R., & Yong, V. W. (2019). Progressive multiple sclerosis: from pathophysiology to therapeutic strategies. Nature Reviews Drug Discovery, 1-18.

Feys, P., Giovannoni, G., Dijsselbloem, N., Centonze, D., Eelen, P., & Lykke Andersen, S. (2016). The importance of a multi-disciplinary perspective and patient activation programmes in MS management. Multiple Sclerosis Journal, 22(2_suppl), 34-46.

Moser, T., Harutyunyan, G., Karamyan, A., Otto, F., Bacher, C., Chroust, V., … & Sellner, J. (2019). Therapeutic Plasma Exchange in Multiple Sclerosis and Autoimmune Encephalitis: A Comparative Study of Indication, Efficacy, and Safety. Brain sciences, 9(10), 267.

Norris, T. L., & Lalchandani, R. (2018). Porth’s Pathophysiology: Concepts of Altered Health States. Lippincott Williams & Wilkins.

Raggi, A., Covelli, V., Schiavolin, S., Scaratti, C., Leonardi, M., & Willems, M. (2016). Work-related problems in multiple sclerosis: a literature review on its associates and determinants. Disability and Rehabilitation, 38(10), 936-944.

Sand, I. K. (2015). Classification, diagnosis, and differential diagnosis of multiple sclerosis. Current opinion in neurology, 28(3), 193-205.

Santos, M., Sousa, C., Pereira, M., & Pereira, M. G. (2019). Quality of life in patients with multiple sclerosis: A study with patients and caregivers. Disability and health journal, 12(4), 628-634.

Thompson, A. J., Banwell, B. L., Barkhof, F., Carroll, W. M., Coetzee, T., Comi, G., … & Fujihara, K. (2018). Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. The Lancet Neurology, 17(2), 162-173.

Toledano, M., Weinshenker, B. G., & Solomon, A. J. (2015). A clinical approach to the differential diagnosis of multiple sclerosis. Current neurology and neuroscience reports, 15(8), 57.