A 34-year-old divorced woman with two children presented with a 3-month history of reduced mobility and was admitted via a casualty department to a general medical unit. The examination findings were those of a moderate spastic paraparesis. Further history from the patient revealed that, 6 years earlier, she had begun complaining of tiredness. She was seen by a number of hospital specialists and a diagnosis of chronic fatigue syndrome was made. Two years after the onset of these symptoms, she had a 2-week episode of lower limb weakness when she was effectively housebound. This recovered spontaneously. Subsequently, she complained of muscle aches and pains, and further assessment by a hospital specialist led to revision of the diagnosis to fibromyalgia. She experienced bladder problems, and she recalled a spell during which she would bend her neck and experience tingling in both hands. Her marriage broke up, and she had increasing difficulty coping with her young children.
Investigation on this current hospital admission included MR imaging of the brain and cord revealing multiple lesions consistent with demyelination, and CSF analysis that was acellular and positive for oligoclonal bands. Relaying the diagnosis to the patient was unusually met with some relief, because she thought that doctors did not believe her symptoms and that she could even be imagining them herself.
Although some researchers have identified a correlation between performance on psychometric testing and the severity of magnetic resonance imaging (MRI) lesions, others have failed to do so.
Mood disorders are also common in MS and include depression, euphoria (much less common than is generally perceived), and psychosis. Depression has lifetime prevalence in MS of approaching 50%. It is likely to be partly reactive to the consequences of the illness (impact on relationships, work, financial loss, problems with self-esteem, pain, and sleep disturbance to name but a few) and also due to some constitutional effect of the disease process. Suicide is an increased risk in MS and may account for as many as 15% of the fatalities.
An overt psychotic episode may be the initial presenting feature of MS, although rare, and in patients with frontal lobe involvement there may be a Kluver-Bucy state, with hyperphagia and loss of usual social and sexual inhibition.
Pain and Paroxysmal Symptoms It is disappointing how many patients are told that pain is not usually a feature of MS. Unfortunately, it will be a feature for almost every patient at some time during the course of the disease. Pain can be classified into two broad categories: paroxysmal pain and chronic pain.
Trigeminal neuralgia is the most common form of paroxysmal pain in MS, and its characteristics are well known. Other phenomena include tonic spasms (Case 1) and Lhermitte phenomenon (Case 3). Tonic spasms are brief, tonic contractions occurring in a hemiparetic distribution and lasting a few seconds to a couple of minutes. No loss of consciousness occurs, but the spasms are often painful and may occur up to 30 times a day. The pathophysiology of the spasms is unclear, but they may occur due to fluxes of ionized calcium at the site of a plaque.
Lhermitte symptom is sometimes erroneously referred to as a sign and results from plaque within the cervical cord. Characteristically, the patient describes electric-like shocks and tingling moving down the spine and into the arms and legs on forward flexion of the neck. Other neck movements may produce similar symptoms. The phenomenon occurs in approximately 2% to 3% of patients as the initial symptom, but it is not specific for MS, because it also occurs in compressive cervical myelopathy and subacute combined degeneration of the cord. All these paroxysmal pain syndromes may remit spontaneously, and those that do not often respond to small doses of carba-mazepine.
Chronic pain is highly prevalent in those with well-established disease and is multi-factorial. It may result from poor posture, spasticity, contractures, lumbar pain, or persistent dysesthesia.
Epilepsy is relatively prevalent in the overall population, and it would therefore not be surprising for MS patients to coinci-dentally have both conditions. However, MS itself does appear to increase the risk of seizures by two- to threefold and may be more prevalent in those with higher loads of cortical and subcortical plaques.
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