Multiple Sclerosis
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Lectures:   Clinical Presentation

  • Introduction

It is important to note that patients with MS have subjective complaints and objective signs that frequently are not attributable to one specific lesion in the CNS. It is usually possible to distinguish at least two or more separate foci of involvement based on the clinical assessment of the patient.

Multiple Sclerosis most often is characterized by episodes of neurological dysfunction followed by periods of stabilization or partial to complete remission of symptoms. These symptoms (relapses or exacerbations) can appear over a few hours or days, can be gradually worsening over a period of a few weeks, or sometimes can present themselves acutely. Depending on a course and a subtype of the disease, these symptoms will either persist or slowly resolve over weeks or months and may even culminate as a complete remissions. A relapsing-remitting pattern is the most common and is characteristic for this disease.

  • Initial Symptoms

Certain signs and symptoms are more common in the early stages of the disease. Patients may be complaining of double or blurred vision, numbness, weakness in one or two extremities, instability in walking, tremors and problems with bladder control, heat intolerance.

As is well known, sensory exam is the most difficult one to perform reliably and accurately in evaluation of patients with neurologic complaints. However, certain distributions of sensory problems can be suspicious for early MS. Among those are:

- ascending numbness starting in the feet;
- bilateral hand numbness;
- hemiparesthesia;
- dysesthesia in one of the above distributions;
- generalized heat intolerance

Objectively the most common sensory findings in the"numb" areas are dorsal column signs, such as reduction of vibration, proprioception and stereognosis, rather than problems with spinothalamic tract.

Usually double vision in MS patients results from a unilateral or bilateral partial of complete internuclear ophthalmoplegia. VI nerve paresis and palsy also have been described as presenting symptoms of MS. III and IV nerves palsy are rather uncommon.

Optic Neuritis is a frequent presenting symptom of MS. It is characterized by blurred vision, a change in color perception, visual field defect i.e.,. Central scotoma, and possible headaches and retro-orbital pain precipitated by eye movements. These symptoms may require neuro-ophthalmologic evaluation, MRI imaging and Visual Evoked Potential studies to establish a degree of optic nerve function.

Motor weakness often is accompanied by upper motor neuron signs, such as mild spasticity, hyperreflexia, and pathologic signs. The most common initial presentation is paraparesis, but weakness can be also found in just one extremity (monoparesis) or all four extremities (quadriparesis).

  • Ongoing Symptoms and Signs

As the disease progresses, the original signs and symptoms may worsen, and the new ones may appear. The most common symptoms and signs include:

  • Motor system:
    -weakness (variable severity mono- and paraparesis, hemiparesis, quadriparesis)
    -increased spasticity resulting in spastic gait
    -pathologic signs (Babinski's, Chaddock's, Hoffmann, Oppenheim's, etc.) -dysarthria

  • Cerebellar signs:
    -incoordination (dysdiadochokinesia, problems with heel-to-shin test)
    -slowing of rapid repeating movements
    -cerebellar ataxia (ataxic gait)
    -scanning speech
    -loss of balance

  • Sensory systems:
    -Lhermitte's sign
    -dysesthetic pain
    -dorsal column signs (i.e.,. severe decrease or loss of vibratory sense and proprioception, positive Romberg's test)

  • Urinary incontinence, incomplete emptying, increased frequency of urination. All of these problems may result in urinary tract infections.

  • Optic disc pallor, atrophy, blurred vision, diplopia, nystagmus, oscillopsia, intranuclear ophthalmoplegia, central scotomas or other visual field defects

  • Cognitive and emotional abnormalities (emotional lability, depression, anxiety)

  • Fatigue

  • Sexual dysfunction

At this stage in the disease, uncommon but important problems may include bowel incontinence, difficulty swallowing, seizures, trigeminal neuralgia, dystonia, hearing loss, and facial nerve (Bell's) palsy.

All of the above-mentioned symptoms can be precipitated by heat, i.e.,. being in a hot, humid environment, or taking a hot bath.

  • Clinical Cases