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Christopher Harrington

Multiple Sclerosis Awareness

Multiple sclerosis (MS) is an often times debilitating disease whose


cause is still largely unknown and whose cure is currently non-existent. While
the root of what causes the initial onset of MS as well as the causes for the
various courses the disease can take remain a mystery, the general
mechanism for how the disease does its damage is well established. Multiple
sclerosis is categorized as an immune-mediated, T-cell driven disease of the
central nervous system characterized initially by demyelination and,
eventually, by axonal destruction and neuronal loss (Ross et al). Essentially,
the body's immune system starts attacking the central nervous system (CNS)
which, when damaged, causes an inability for the body to properly
communicate with itself.
In reality, the full complexity of what happens to the central nervous
system of someone with multiple sclerosis is not only outside the scope of
this paper, but it is also a topic which is still under investigation in the
scientific community. However, the basic mechanisms can be summed up
and given as a satisfactory explanation of the biological processes involved.
First, in order to understand what happens in the body of someone with MS,

it is important to first have a general understanding of the body's central


nervous system as well as certain facets of the immune system.
To give a brief overview, the main components of the CNS are the brain
and spinal cord which use nerve cells, called neurons, to send and receive
signals from all over the body. These neurons in turn have axons that
facilitate the communication between different neurons. Beyond that, the
final piece of the CNS with relevance to understanding MS is the myelin
sheath which is a lipid rich membrane that acts as a protective covering for
the axons (Waxmen). It is also theorized that myelin basic protein is the T-cell
antigen that causes the immune-mediated reaction (Hauser et al).
In addition to an understanding of the CNS, it is also important to
identify a main component of the immune system; namely, the T-cells and
macrophages. T-cells are white blood cells and can be split up into several
categories based on their specific function, but the only ones necessary for
our understanding of MS are the Helper T-cells and the Cytotoxic T-cells.
Fundamentally, the role of Helper T-cells is to, ...augment the immune
response by recognizing the presence of a foreign antigen and then
stimulating antibody production...; while the Cytotoxic T-cell's role is to,
...directly attack and destroy cells bearing antigenic material
(nationalmssociety.org). Macrophages are also white blood cells which,

digest debris (like dead cells) and foreign particles through the process of
phagocytosis (Macrophages).
Now, with those brief explanations of the CNS and the T-cells, the
damaging processes involved in multiple sclerosis can more easily be
explained. The first step that occurs in patients with MS is that the Helper Tcells identify an antigen in the myelin which initiates the immune-mediated
response. Once the antigen is detected, a lesion forms by causing
perivencular cuffing by inflammatory mononuclear cells, predominantly T
cells and macrophages (Hauser et al). In the resulting lesion is where the
Cytotoxic T-cells and macrophages go to work. The Cytotoxic T-cells destroy
the myelin and oligodendrocytes (myelin producing cells) and the
macrophages clean up the debris. This process which occurs in all cases of
MS is known as demyelination and leaves the underlying axons exposed
(Hauser et al). Interestingly, while damage to the axon occurs in every
newly formed MS lesion, it is still not entirely known what causes the axonal
injury (Hauser et al). However, as the disease progresses and more lesions
form, the cumulative axonal loss is considered to be the major cause of
progressive and irreversible neurologic disability in MS (Hauser et al).
Though this is a simplified description of the process that occurs in someone
with MS, its severity should be clear given the importance of the central
nervous system.

To go on, the symptoms that someone with MS can experience are not
only debilitating, but also quite expansive. Due to the damage to the myelin;
nerve impulses traveling to and from the brain and spinal cord are distorted
or interrupted, producing a wide variety of symptoms
(nationalmssociety.org). Symptoms caused by multiple sclerosis are so
numerous and varied that it is possible for two people with MS to have two
completely different sets of symptoms depending on the location and
severity of lesions within the CNS (Hauser et al). On the other hand, there
are some symptoms which are typical in many MS patients which include
blurred vision (or blindness in one eye), muscle weakness, and trouble
maintaining balance while walking (ataxia), just to name a few (Stanfield).
Symptoms can also vary depending on the severity and stage of the disease.
Multiple sclerosis is broken up into four types: relapsing/remitting MS (RRMS),
secondary progressive MS (SPMS), primary progressive MS (PPMS), and
progressive/relapsing MS (PRMS) (Hauser et al). Relapsing/remitting MS is the
most common at onset of the disease and consists of discrete attacks that
generally evolve over days to weeks (Hauser et al). Secondary progressive
MS begins as RRMS and then changes to a steady deterioration in function
(Hauser et al). Primary progressive MS is like SPMS except that it occurs from
the onset of the disease and progressive/relapsing MS is an overlap of PPMS
and SPMS (Hauser et al). While some types of MS are considered to be more
mild, Most patients with clinically evident MS ultimately experience

progressive neurological disability (Hauser et al). However, while MS can be


debilitating, Mortality as a direct consequence of MS is uncommon, and the
25-year survival estimate is only decreased by 15% (Hauser et al).
Current data suggests that there are roughly 2.5 million people
worldwide currently living with multiple sclerosis (Hauser et al) . Also, it is
generally diagnosed between the ages of 20-40 (Ropper et al). However,
accurately diagnosing this disease is no easy task. The typical tests that are
used in the diagnostic process for multiple sclerosis are MRIs, spinal taps,
and evoked potentials, but there are several disorders that can present
themselves with symptoms identical to those found with multiple sclerosis so
there is no one test that can be used to give a definitive diagnoses. One
example of how a test for MS can be inconclusive is given in The Principles
and Practice of Hospital Medicine when it states, Oligoclonal bands on
electrophoresis are the most sensitive CSF test for MS, but these may also be
present in infectious and inflammatory conditions, such as Lyme disease,
HIV, and neurosarcoidosis (Ross et al). Generally, the only way to arrive at a
confident diagnoses of multiple sclerosis is with, ...evidence of
dissemination of disease in both space and time, which essentially means
that there needs to be lesions of varying age in several different parts of the
central nervous system (Ross et al). This requirement of evidence of lesions
in space and time is one of the factors that makes diagnosing multiple
sclerosis so challenging, especially in patients with newer cases of MS where
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the disease has not progressed to a point where that type of evidence is
available. Given all of the obstacles in properly diagnosing multiple sclerosis,
arriving at an accurate incidence figure has been virtually
impossible(nationalmssociety.org). Although, it is commonly reported that
the incidence of MS is roughly two to three times higher for women than men
(Ropper et al).
In addition to multiple sclerosis being a tricky disease to diagnose, it is
also not a particularly easy disease to predict. Even so, there has been
enough data gathered about MS to at least identify some common factors
among the majority of people who contract the disease. Firstly, there is a
genetic factor that contributes to one's likelihood of contracting MS. Along
with African Americans being at lower risk than whites..., it also states in
Principles of Neurology that, Approximately 15 percent of MS patients have
an affected relative. Another major factor that seems to play a role is the
environmental factor. Not only are people more likely to develop MS if they
live in a higher latitude , but the risk is also somewhat greater among rural
than among urban dwellers (Ropper et al). One more factor that has been
identified is a person's socioeconomic status as stated in Harrison's
Principles of Internal Medicine; MS risk also correlates with high
socioeconomic status, which may reflect improved sanitation and delayed
initial exposures to infectious agents. While there are several identified

factors that may contribute to one's likelihood of contracting MS, there are
no definitive answers which makes MS an unpreventable disease.
To continue, treatment of MS can be broken up into two main
categories: direct treatment of MS and treatment of MS symptoms. Multiple
sclerosis of types other than PPMS can be treated directly with various
disease modifying agents that slow down the progression of the disease
and reduces the number of relapses and results in better long-term
outcome (Ross et al). While these disease modifying agents may aid in
slowing the progression of the disease, none have been shown to stop the
disease or reverse any of the damage that has been done (Ropper et al). The
second category of treatment, treating the symptoms, consists of many
various methods depending on the symptom, but generally boils down to
medication and physical therapy. Harrison's Principles of Internal Medicine
states with regard to symptomatic treatment that, For all patients, it is
useful to encourage attention to a healthy lifestyle, including maintaining an
optimistic outlook, a healthy diet, and regular exercise as tolerated (Hauser
et al). Due to how little is known about the causes of MS, all treatments for it
are geared mainly toward preventing the disease from progressing rather
than curing the disease. Unfortunately, while there are no cures and only
moderately effective treatments for MS, the average cost per person with MS
still ranges from $8,528-$54,244 per year (Adelman et al). There is such a

wide gap in the two ends of the cost range simply due to the variance in
severity of the disease.
Overall, multiple sclerosis is a disease with devastating potential. It is
nearly impossible to predict and attacks its victims in one of the most vital
parts of the human anatomy. On the other hand, it is also a disease that is
continuously being studied and researched; perhaps with major
breakthroughs ahead. With new experimental therapies being introduced on
a consistent basis, life for people with MS may soon turn a corner.

Works Cited

Ross, John J., and Allan H. Ropper. "Chapter 213. Multiple Sclerosis." Principles
and Practice of Hospital Medicine. Eds. Sylvia C. McKean, et al. New York, NY:
McGraw-Hill, 2012. n. pag. AccessMedicine. Web. 14 Nov.
2014.<http://accessmedicine.mhmedical.com/content.aspx?
bookid=496&Sectionid=41304201>.

Hauser, Stephen L., and Douglas S. Goodin. "Chapter 380. Multiple Sclerosis and
Other Demyelinating Diseases." Harrison's Principles of Internal Medicine,
18e. Eds. Dan L. Longo, et al. New York, NY: McGraw-Hill, 2012. n.
pag.AccessMedicine. Web. 14 Nov.
2014.<http://accessmedicine.mhmedical.com/content.aspx?
bookid=331&Sectionid=40727196>.

Ropper, Allan H., et al. "Chapter 36. Multiple Sclerosis and Other Inflammatory
Demyelinating Diseases." Adams & Victor's Principles of Neurology, 10e. Eds.
Allan H. Ropper, et al. New York, NY: McGraw-Hill, 2014. n.
pag.AccessMedicine. Web. 14 Nov.

2014.<http://accessmedicine.mhmedical.com/content.aspx?
bookid=690&Sectionid=50910887>.

Waxman, Stephen G. "Chapter 2. Development and Cellular Constituents of the


Nervous System." Clinical Neuroanatomy, 27e. Ed. Stephen G. Waxman. New
York, NY: McGraw-Hill, 2013. n. pag. AccessMedicine. Web. 14 Nov.
2014.<http://accessmedicine.mhmedical.com/content.aspx?
bookid=673&Sectionid=45395958>.

Stanfield, Cindy L. Principles of Human Physiology. 5th Edition. New


York: Pearson, p.696. 2013. Print.

Nationalmssociety.org. National MS Society. Web. 14 Nov. 2014

Macrophages. Regenerative Medicine. Duquesne University. Web. 14


Nov. 2014. <http://sepa.duq.edu/regmed/immune/macrophages.html >

Adelman, Rane, Villa. The cost burden of multiple sclerosis in the


United States: a systematic review of the literature. Journal of Medical
Economics 16.5 (2013): 639-647. Informa Healthcare. Web. 14 Nov.
2014.
<http://informahealthcare.com/doi/abs/10.3111/13696998.2013.778268 >

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