A case of multiple sclerosis final! website (2)

A CASE OF MULTIPLE SCLEROSIS : Follow Up Since 1997

Dr. L. K. MalhotraMBBS, MD, DM (Neurology)

Consultant NeurologistNew Delhi, India

BACKGROUND

• Tertiary neurocentre : 0-2 new patients of MS/ yr

• Majority patients have no insurance cover

• Patient can consult any neurologist throughout India anytime



• 22 yrs Female SM• On 22/7/97 H/O Acute onset ataxia without

headache, vomiting, fever, tinnitus, deafness

• No past H/O fever, immunization, rash, visual loss. H/O myocarditis in childhood. No DOE

• O/E : Fundus normal, Gait ataxia, brisk jerks, extensor plantars

• Investigations : Haemogram, Blood sugar, liver, renal function tests, Rheumatoid factor, ANF, DsantiDNA Ab, Se B12 levels, ECG, X - ray chest ---- normal

• HIV and VDRL ---- negative• CSF : cytology : 20 cells L, Proteins : 80

mg, sugar : 40mg, oligoclonal bands ----negative

• VEP : 112 ms ----- bilateral


SM 31 / 7 / 1997

SM 31 / 7 / 1997

SM 31 / 7 / 1997

• Treatment : I.V. -- M.P. 5 g followed by oral steroids for 2 weeks

• Clinical and radiological improvement seen

A CASE OF MULTIPLE SCLEROSIS : 17 YEARS FOLLOW-UP

SM 11 / 10 / 1997

SM 11 / 10 / 1997

SM 17 / 3 / 1998

SM 9 / 3 / 1999

SM 9 / 3 / 1999

• Oct 2000 : worsening of ataxia

• MRI brain : Fresh brain stem and supra tentorial lesions

• Treatment : I.V. M.P. 5 g

• Partial Improvement


• Nov 2000 : started on Avonex


• Aug 2001 : Worsening of ataxia, Tremulousness on standing, limb ataxia

• MRI brain : fresh lesion in medulla• Treatment : I.V. M.P. 3 g, Azathioprine added.• Partial improvement


SM 17 / 8 / 2001

• Sept 2002 : worsening of ataxia, dysarthria, gaze evoked nystagmus, limb and gait ataxia, brisk jerks, plantar extensors.

• MRI brain : fresh brain stem lesion

• Treatment : I.V. M.P 3 g


SM 18 / 9 / 2002

• April 2003 : worsening of symptoms. Oral steroids for 3 weeks minimal improvement

• July 2003 : worsening of symptoms. Oral steroids started. No improvement.

• MRI Brain : fresh parasaggital lesion

• MRI cervical and dorsal spine : sub acute to chronic plaque seen.

• I.V. M.P. 3 g, no improvement


SM 23 / 4 / 2003

SM 25 / 7 / 2003

SM 25 / 7 / 2003

SM 25 / 7 / 2003

• Aug 2003 : dysarthric, gaze evoked nystagmus, limb and gait ataxia, ankle clonus, brisk jerks, extensor plantars

• Needed support to walk.

• RRMS SPMS


SUMMARY• 22 yrs Female• 7 / 1997 : First attack --- I.V. M.P.• 10/2000 : Second attack --- I.V. M.P.• 11/2000 : Avonex started• Relapses : Aug 2001, Sep 2002, Apr 2003,

Jul 2003 Progressive course• Aggressive Disease since Sep 2002


Treatment options :

• Mitoxantrone

• Cyclophosphamide

• I.V. MethylPrednisolone monthly

• I.V. Immunoglobulins

• G.A.

• Injection Rebif


Pulse therapy• I.V. cyclophosphamide with I.V. high dose steroids• Cyclophosphamide 1000 mg/m2 /course (approx. 1500-2000 mg for average person)• I.V. Methylprednisolone 750 mg BD or

Dexamethasone 150 mg BD• Monitor blood counts, urine, X-ray chest, ECG• Anti – emetics before cyclophosphamide• Hydration I.V. / oral


PULSE THERAPY1. 27 Oct 2003 --------- 6 weeks2. 08 Dec 2003 --------- 6 weeks3. 13 Jan 2004 --------- 6 weeks4. 03 Mar 2004 --------- 2 months5. 05 May 2004 --------- 2 months6. 06 Jul 2004 --------- 4 months7. 13 Nov 2004


• No urinary / menstrual problem. Mild alopecia.

• Injection Rebif 22 microgm thrice a week since Nov 2004 till now.

• And no relapse since then.


SM 10 / 2 / 2006

SM 10 / 2 / 2006

SM 10 / 2 / 2006

SM 10 / 2 / 2006

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A case of multiple sclerosis final! website (2)