Multiple sclerosis

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  • CNS myelin destruction causes variable motor, sensory, visual and cerebellar dysfunction[1]


  • Relapsing/remitting (most common)
    • Relapse (days-months) followed by remission
  • Secondary progressive
    • Relapses and partial recoveries occur, but disability does not fade away between cycles
  • Primary progressive
    • Symptoms progress slowly and steadily without remission
  • Progressive relapsing
    • Similar to primary progressive but with superimposed flares

Clinical Features

  • Classic patient has multiple presentations for neuro symptoms of different areas of pathology
    • Patient often has resolution of the earlier symptoms
  • Symptoms worsen with increases in body temperature, classically after hot showers (Uhthoff's phenomenon[2])
  • Muscle/sensory signs:
    • Lower extremity weakness usually worse than upper extremity
    • Upper motor neuron signs:
      • Hyperreflexia
      • Positive Babinski
    • Decrease in proprioception/pain/temperature sensation
    • Lhermitte sign
      • Electric shock sensation radiating down back into arms/egs from neck flexion
      • If the discomfort is severe, carbamazepine or gabapentin may be beneficial for some patients.
  • Optic neuritis
  • Internuclear ophthalmoplegia
    • Abnormal eye adduction bilaterally and horizontal nystagmus
    • Convergence (both eyes center medially) is preserved
  • Dysautonomia

Differential Diagnosis



MRI brain with contrast of a patient in her mid-20s with new onset MS. Large lesion in left parietal area.
MRI brain with contrast of same patient with new onset MS with another lesion in the left cerebellum.
  • CSF
    • Elevated protein and gamma-globulin (increased oligoclonal bands)
  • MRI
    • Multiple lesions in supratentorial white matter, paraventricular area, spinal cord
  • MRI with GAD of brain (+/- spine) and orbits (if optic neuritis suspected)
  • CBC, Chemistry
  • Urinalysis


  • Fever must be reduced to minimize weakness associated with elevated temperature

Infection Treatment

  • Antibiotics or surgical control of any infectious sources

Steroids and Immunomodulators

  • High-dose steroid therapy for relapses in the form of oral or intravenous methylprednisolone (1000 mg)[3]
  • Suppression therapies
    • IFN B, Glatiramer, Estriol (usually not in ED)


  • Hospitalization indicated for:
    • Any disease exacerbation associated with significant morbidity
    • IV antibiotics or steroid therapy required
    • Depression and significant risk of suicide

See Also


  1. Multiple sclerosis: a practical overview for clinicians. British Medical Bulletin, Volume 95, Issue 1, September 2010, Pages 79–104.
  2. Flensner G, et al. "Sensitivity to heat in MS patients: a factor strongly influencing symptomology-an explorative survey". BMC Neurol. 2011. 11:27.
  3. Le Page et al. Oral versus intravenous high-dose methylprednisolone for treatment of relapses in patients with multiple sclerosis (COPOUSEP): a randomised, controlled, double-blind, non-inferiority trial. Lancet. 2016 Jan 23;387(10016):340.