Multiple Sclerosis (Exacerbation)

Abstract

Approximately 85 % of patients with multiple sclerosis (MS) present with the relapsing-remitting form of the disease. A high frequency of relapses in the first year after diagnosis is associated with poor prognosis. Exacerbations of multiple sclerosis are characterized by episodes of focal neurological disturbance lasting more than 24 h and preceded by a period of clinical stability lasting 30 days or more. Fluctuations in symptoms with fever, heat, or infection may not be considered true exacerbations since in these contexts previous deficits may be simply “unmasked.” For this reason, screening labs should include a CBC and urinalysis to help exclude intercurrent infection. Contrasted brain MRI is useful to assess any new (typically enhancing) lesions which may be responsible for the acute exacerbation. Lumbar puncture and CSF analysis are not necessary if the diagnosis of multiple sclerosis is already established. However, it may show a variable degree of pleocytosis and increased total protein, myelin basic protein, and oligoclonal bands with an elevated IgG synthesis rate and IgG index. Visual evoked potentials remain abnormal years after an episode of optic neuritis. Somatosensory and brainstem auditory evoked potentials are abnormal in at least one-third to one-half of patients with MS.

The mainstay of treatment for acute exacerbations is high-dose intravenous corticosteroids.

Disease-modifying therapy should be initiated or optimized to achieve long-term control. The most commonly available agents are injectable interferon beta formulations and glatiramer acetate. For more refractory cases, natalizumab may be employed. Recently, oral agents including fingolimod and teriflunomide have become more convenient options.