Jurnal Profesi Medika : Jurnal Kedokteran dan ISSN 0216-3438 (Print).

ISSN 2621-1122 (Online) Kesehatan

MULTIPLE SCLEROSIS RELAPSING REMITTING PROGRESSIVE TYPE

Nora Fitri1*, Basjiruddin Ahmad 2, Yuliarni Syafrita 2

1
Faculty of Medical,University of Andalas, Padang, Indonesia
2
Faculty of Medical, University of Andalas Universitas Andalas / Dr. M. Djamil General Public
Hospital, Padang, Indonesia

*Correspondence email: nora.ppds2017@gmail.com

ABSTRACT

Multiple sclerosis (MS) is the most common neurologic demyelinating disease in high-income
countries. The causes of MS are multifactorial involve genetics and the environment in which
immune cell infiltration occurs across the blood-brain barrier, causing inflammation, demyelination,
gliosis, and neuroaxonal degeneration substantia grisea in the central nervous system. A 23-year-old
female patient was treated with four limbs weakened since two weeks ago accompanied by blurred
vision, pain, cramps, and stiffness in the back muscles and legs. The patient has experienced the
same complaint before. Clinical findings reveal lhermitte signs, atrophy papillae, and tetraparesis. On
thoracic vertebral MRI examination without contrast and brain MRI with contrast obtained multiple
sclerosis lesions. Patients receive steroid and antidepressant therapy. MS needs to be studied further
because this number of cases began to emerge.

Keywords: Autoimmune; Demyelination; Lhermitte Sign; Multiple Sclerosis

weeks ago. These conditions had occurred
INTRODUCTION gradually since one year ago, where
Multiple sclerosis (MS) is the most conditions began with weakness in both legs.
common neurological demyelinating disease These conditions were followed by weakness
in high-income countries. The median global in both arms, which was felt two weeks later.
prevalence of MS increased from 30 per The weakness started in the left arm,
1
100,000 in 2008 to 33 per 100,000 in 2013. followed by the right arm. Since two weeks
Multiple sclerosis is caused by infiltration of ago, she only could move his toes and often
immune cells across the blood-brain barrier, let go of holding objects. These conditions
causing inflammation, demyelination, gliosis, accompanied by blurred vision since one
and neuroaxonal degeneration of the grisea week ago. Pain, cramps, stiffness in the back
substantial of the central nervous system and legs muscles, and irritability and anger
(CNS).2 Causes of MS are multifactorial, have often occurred for one year. For two
involving both genetics and the environment. months, the patient has also had a catheter
The gene most strongly associated with MS is attached.
the HLA-DRB1 * 1501 MHC class II She had experienced the same
3,4,5 complaint in 2016, 2017, and January 2018.
haplotype linked to immune function.
A history of blurred vision also occurred 2x
Additionally, MS has been linked to vitamin
in June 2017 and September 2017. In
D deficiency, connected to several other
December 2017, an MRI of thoracic vertebra
autoimmune diseases.3.6 without contrast was performed where
multiple tubular-shaped lesions were seen in
CASE PRESENTATION
the spinal cord as high as Th3- Th6 with
A twenty-three-year-old woman was
transverse myelitis impression (Figure 1).
treated at the neurology department of RSUD
M. Djamil with weak four limbs since two

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Jurnal Profesi Medika : Jurnal Kedokteran dan ISSN 0216-3438 (Print). ISSN 2621-1122 (Online) Kesehatan
below. Physiological and pathological
reflexes are increased. Laboratory test when
she was admitted showed anemia (Hb = 9.8 g
/ dl (normal level = 12-14 g / dl)) and mild
hypokalemia (K = 3.3 mmol / L (normal level
= 3.5-5.1 Mmol / L))
Based on clinical findings, physical
examination, and investigations, the patient
was diagnosed with relapsing-remitting
multiple sclerosis (RRMS). During
hospitalization, patients received
methylprednisolone 4 x 250 mgs (iv),
ranitidine 2x 50 mgs (iv), ibuprofen 2 x 400
mgs (oral) and fluoxetin 1 x 10 mgs (oral).
She showed clinical improvement in the form
of improvement in limb weakness and
improvement in vision. During treatment, the
patient also received gabapentin 2 x 300 mgs
(oral) to reduce pain, cramps, and stiffness in
the back muscles.
Figure 1. MRI of Thoracal Vertebra without
contrast (December 2017)

In January 2018, lumbar puncture was

performed with macroscopic smooth flow,
clear color, none +1, pandy +1, and
microscopic cell count of 1 / mm3, CSF
glucose 91 mgs / dl, blood glucose 195 mgs /
dl, and protein 800 mgs / l . Contrast brain
MRI was performed with results within
normal limits. In February 2018, an MRI of
the thoracic vertebrae without contrast was
performed, showing a small size cystic spinal
cord dilatation with hydrosyringomyelia as
high as C1-Th12 and susp. Multiple sclerosis
at the level of Th1-2 and Th4-5 (Figure 2).
The neurosurgeon performed a drain with an
indication of hydrosyringomyelia. After the
operation, the patient can stand by holding
the wall.
Physical examination showed a
moderate general condition, cooperative
composition with blood pressure (BP) 110/70
mmHg, pulse 108 x/minute. Lhermitte's sign Figure 2. MRI of the Thoracal Vertebra
was found, and on funduscopy, the without contrast (February 2018)
impression of papillae atrophy of the right At the time of treatment, a brain MRI
and left ocular. Visus OD 1/300 and OS 1 / ∞. was performed in contrast to the results
Superior motor strength 344/443 and inferior showing multiple hyperdense lesions in the
111/111. Sensory hyperesthesia is found at left lateral paraventricle and left parietal lobe
the level of the C5 dermatome and below. (on T2, Flair, and DWI), the lesion did not
Urinary retention and sweat secretion are enhance post contrast administration with
impaired at the level of C5-6 dermatome and multiple sclerosis impressions.
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Jurnal Profesi Medika : Jurnal Kedokteran dan ISSN 0216-3438 (Print). ISSN 2621-1122 (Online) Kesehatan
disturbances (optical neuritis), weakness of
all four limbs (myelitis), pain, cramps,
stiffness in muscles and joints, and phases of
relapse and remission. The MS course can be
relapse
remission or progressive but usually involves
multi-phases and multi-focal (disseminated in
time and location). Where reversible episodes
of neurologic deficit last for several days to
weeks characterize the early stages of the
Figure 3. disease. Over time, clinical and cognitive
deficits develop become irreversible. A
minority of patients have a progressive course
of the disease from baseline.8,9
The clinical features of myelitis in MS
are usually asymmetrical, progressive over
hours to days, and usually, there is spinter
involvement.2,7 Optic neuritis may be acute or
subacute with bilateral or unilateral visual
Brain MRI with contrast with multiple impairment, sometimes accompanied by
sclerosis impression (December 27th, 2018) retroorbital or ocular pain that worsens with
eye movement. There is usually a complete or
The patient went home with motor partial improvement in the patient.2
strength 344/222 and vision 1/60 ODS and Apart from physical complaints, these
was given 2x300 mgs gabapentin, 2x400 mgs patients also tend to be more sensitive and
ibuprofen, 2x150 mgs ranitidine, and 3 x 8 easily irritated and tired. Mood changes that
mgs methylprednisolone. occur in MS, including depression (50%),
euphoria, and psychosis. Fatigue is common
DISCUSSION in MS patients, where it reaches 84%. Various
Multiple sclerosis (MS) is an forms of fatigue can occur due to MS disease
autoimmune disease, which rarely occurs. or caused by related factors such as
Because of this rarity, MS is a diagnostic depression, lack of sleep due to nocturia or
challenge in itself. MS is usually diagnosed seizures, poor appetite.10 Depression in MS
between the ages of 20 and 40 and twice as may involve cytokines that are essential
many women as men.2,7,8 Cause of MS is components of immune activation during
multifactorial, combining genetic and inflammation and are involved in an
environmental factors. However, MS's cause oligodendrocyte injury, axonal degeneration,
and neuronal dysfunction, significant MS
remains largely unknown.1 Pathological
pathology features. Cytokines are molecules
feature of MS is that it is characterized by
produced by immunocompetent cells that
involving the brain, spinal cord, and optic
mediate and coordinate communication
nerve. Focal lesions are thought to be caused
by immune cells' infiltration, including T between cells of the immune system.8
cells, B cells, and myeloid cells, into the Pain, cramps, and stiffness in joints and
parenchymal of CNS where the injury is muscles also occur in these patients. Impaired
located.8,9 muscle function in MS patients can manifest
in involuntary muscle stiffness or movement
This patient's clinical features are visual
and limited muscle function capacity, which
 focuses on spasticity, spasms, and weakness. Lack of inhibition of the
The primary mechanism of spasticity is the oligointramedular pathway in the brain or
hyperexcitability of α motor neurons caused polysynaptic in the spinal cord,
by decreased secondary descending inhibitory
signals that damage of CNS.11

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Jurnal Profesi Medika : Jurnal Kedokteran dan ISSN 0216-3438 (Print). ISSN 2621-1122 (Online) Kesehatan
neurosyphilis, intracranial masses, vascular
physiologically mediated by the lesions, and hereditary neurological
neurotransmitter γ-aminobutyric acid 12
diseases. The more important CSF message
(GABA), results in reflex hyperactivity. is to rule out other possible diagnoses. The
Symptoms include muscle stiffness and/or high incidence of infection in Indonesia
spasms, pain or discomfort, loss of function requires considering the possibility of
in the upper / lower extremities, and infection before establishing a diagnosis of
difficulty maintaining a standing or sitting MS.
posture with excessive reflexes, clonus, The MS diagnosis was confirmed by the
seizures. Spasticity increases with stress and revised McDonald Criteria of the
harmful stimuli (e.g., pain, pressure, urinary International Panel on the Diagnosis of MS
tract infections, and usually shows (Table 1). She had ≥ two attacks; there is
spontaneous fluctuations (usually increases clinical evidence, so it does not require
at night).11 additional data to make a diagnosis. MS is
Imaging examination that must be done divided into several types based on the course
to establish MS is MRI. Besides, evoked of the disease in the form of relapsing
potential (EP) can also be performed, remitting MS (RRMS), secondary progressive
especially visual evoked potential (VEP) and MS (SPMS), primary progressive MS
CSF examination. On MRI examination, you (PPMS), progressive relapsing MS (PRMS),
will see a Disseminated Lesion in Space and benign MS (Table 2).12 She was admitted
(DIS) image on the T2 section at least 2 out to the RRMS type.
of 4 areas, including periventricular, MRI examination of the spinal cord in
juxtacortical, infratentorial, and spinal MS very rarely extends beyond two vertebral
12
cord. segments. Generally, the lesions are short,
EP examination aims to measure the asymmetrical, and located in the spinal cord
electrical activity of the brain against stimuli section's posterior segment.12
in specific sensory nerve pathways. EP can At the time of complaint of relapse, the
detect a decrease in electrical conduction patient received high intravenous doses of
caused by damage due to demyelination along methylprednisolone therapy. Treatment in
a pathway. However, the degree of damage is MS is divided into therapy at relapse and
so small that it is not visible on clinical long-term therapy. They are using
examination.12 corticosteroids, intravenous immunoglobulin
CSF examination is performed to help (IVIG), or plasma exchange at the time of
determine MS's diagnosis and rule out other relapse. Glucocorticoids in the form of IV or
possible diagnoses, especially intracranial oral methylprednisolone at a dose of 0.5-1 g
infections. In CSF, an increase in the per day for 3-5 days. Long-term therapy in
immunoglobulin G (IgG) index will be the first line uses interferon-β, glatiramer
obtained, or the discovery of ≥ 2 oligoclonal acetate, and fingolimod, while in the second
bands (OCB), indicating a demyelination line using mitoxantrone, natalizumab.13,14,12
process due to inflammation. IgG and OCB In addition, we can also use
tests have high sensitivity but are not specific immunosuppressants mycophenolate mofetil
for MS. OCB can also be found in other (MMF), azathioprine, methotrexate, and
diseases such as SLE, paraneoplastic cyclophosphamide. But its effectiveness still
syndrome, neurosarcoidosis, meningitis, needs further study. Studies show that 55% of
 patients do not experience any worsening of immunosuppressive therapy, symptom
the condition with cyclophosphamide specific therapy is an important component of
therapy. Other studies have shown the same MS patients' comprehensive management.
effect of both azathioprine and MMF. Further This therapy aims to reduce complaints that
research is needed about the effectiveness of can lead to impaired functional ability and
immunosuppressants in MS.2,14 quality of life. She received phenytoin,
Apart from immunomodulation and gabapentin, and pregabalin therapy to reduce

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Jurnal Profesi Medika : Jurnal Kedokteran dan ISSN 0216-3438 (Print). ISSN 2621-1122 (Online) Kesehatan
of tricyclic antidepressants (such as
spasticity and pain. To reduce spasticity can nortriptyline and desipramine) can help
use diazepam 5-30 mgs/day, gabapentin 300- incontinence (because they are
3600 mgs/day, tizanidine 2-4 mgs/day or anticholinergic) as well as treat neuropathic
baclofen 10-120 mgs/day.2,11,14 To reduce pain or duloxetine, which are also effective in
pain in joints and muscles then can use treating pain. Neuropathy or bupropion is
amitriptyline 25-150 mgs/day, gabapentin indicated for the treatment of smoking and
200-1600 mgs/day, 200-400 mgs/day depression.16
lamotrigine or 150-600 mgs/day Multiple sclerosis (MS) is an
2,14,15
pregabalin. To overcome fatigue in these inflammatory disease of the CNS that results
patients, can use amantadine, modafinil , in progressive neurological regeneration and
pamoline.16 neurological disability. MS most commonly
Depression can be viewed as a clinical affects young adults, especially women.
symptom and a complication of MS, so the Many cases of MS are starting to emerge
management of depression is an integral part along with the improvement of supporting
of general MS management. To treat tools such as imaging that complement the
depression in these patients, fluoxetin 1x10 clinical findings of MS patients so that the
mgs was used. The approach to treating diagnosis can be made early, sensitive, and
depression in MS patients can be carried out precise.
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