60 Multiple sclerosis
Patient 2
Salient features
Examination
• Spastic paraparesis (increased tone, upgoing plantars, weakness, brisk reflexes and ankle or patellar clonus). Spasticity is quantified using the Ashworth scale, which scores muscle tone on a scale of 0–4 with 0 representing normal tone and 4 severe spasticity
• Impaired coordination on heel–shin test (if there is marked weakness, this test may be unreliable).
• Check abdominal reflexes (absent or diminished in over 80% of cases)
• Tell the examiner that you would like to look for optic atrophy and cerebellar signs.
Questions
What investigations would you consider?
• Spinal radiography, including both cervical and thoracic regions
• Lumbar puncture: total protein concentration may be raised (in 60% of cases), with an increase in the level of immunoglobulin G (in 40%) and oligoclonal bands (in 80%) on electrophoresis
• Visual evoked potentials: despite normal visual function, there may be prolonged latency in cortical response to a pattern stimulus. This indicates a delay in conduction in the visual pathways
• MRI of brain: about 50% of patients with early multiple sclerosis in the spinal cord show abnormal areas in the periventricular white matter
• Serum vitamin B12 to exclude subacute degeneration of the spinal cord.
Advanced-level questions
What are the clinical categories of multiple sclerosis?
• Relapsing-remitting: episodes of acute worsening with recovery and a stable course between relapses
• Secondary progressive: gradual neurologic deterioration with or without superimposed acute relapses in a patient who previously had relapsing–remitting multiple sclerosis
• Primary progressive: gradual, nearly continuous neurologic deterioration from the onset of symptoms
• Progressive relapsing: gradual neurologic deterioration from the onset of symptoms but with subsquent superimposed relapses.
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