Oral Colonization by Candida Species in Patients with Multiple Sclerosis

INTRODUCTION

Multiple sclerosis (MS) is a chronic inflammatory demyelinating autoimmune disease that affects the central nervous system. Since immune system plays a key role in this disease, patients with MS can present higher risk of infections.

PURPOSE

This study aimed to investigate the prevalence of Candida spp. in the oral cavity of MS patients in relation to a control group METHODS: In total, 100 individuals were selected: 55 diagnosed with MS and 45 healthy individuals (control group). Saliva samples were collected and seeded in culture media selecting for Candida. Following an incubation period of 48 h, colony-forming units (CFU mL^-1) were counted and colonies were isolated for Candida species identification by multiplex PCR. The results were analysed by chi-squared and Mann-Whitney U statistical tests considering a significance level of 5%.

RESULTS

Candida spp. were confirmed in the oral cavity of 50.09% patients in the MS group and 35.55% individuals in the control group. In individuals positive for the growth of Candida spp., the median values of Candida colonies were 220 CFU mL^-1 for the MS group and 120 CFU mL^-1 for the control group. However, no statistically significant differences were observed between groups for both prevalence and CFU mL^-1 count. Of the Candida species identified, 73.91% were C. albicans, 21.73% C. glabrata, 2.17% C. tropicalis, and 2.17% C. krusei.

CONCLUSIONS

The colonization of Candida spp. in the oral cavity of individuals with multiple sclerosis was higher than in the control group; however these findings were not proven to be statistically significant.

Multiphasic disseminated encephalomyelitis associated with herpes virus infection in a patient with TLR3 deficiency

We report a case of a 14-year-old girl that presented headache, amaurosis, drowsiness, fever, vomiting and diffuse reduction of muscle strength. She had been diagnosed with ADEM one year before and had a previous diagnosis of Toll-Like 3 receptor deficiency. Cerebrospinal fluid analysis revealed pleocytosis (28/mm³, 12/mm³ red blood cells, 70% lymphocytes cells, 2% monocytes cells, 28% neutrophils), normal total protein (38 pg/mL) and normal glucose level (53/mm³). Studies for CSF oligoclonal bands and serum anti-MOG were negative but polymerase chain reaction (PCR) testing was positive for herpes virus 1. In the first ADEM episode, PCR for herpes virus was also positive. Magnetic resonance imaging (MRI) of the brain revealed disseminated hyperintense lesions on T2-weighted and FLAIR images in the white matter of frontal, parietal and temporal lobes, corresponding to extensive asymmetric areas of demyelination that produced mass effect and gadolinium enhancement. Electroencephalography demonstrated irregular diffuse and generalized slow-wave activity with predominance in frontal region. The diagnosis of multiphasic disseminated encephalomyelitis (MDEM) triggered by herpes simplex virus was made. Herpes virus is a neurotropic virus that can cause a wide variety of neurological infection-triggered autoimmune disorders and that is particularly damaging to the central nervous system in situations of impaired immune system. TLR3 is expressed in astrocytes and dendritic cells of the central nervous system and is essential for natural immunity to herpes simplex. TLR3-deficient patients have already been described with herpes simplex encephalitis. TLR3 deficiency may predispose and explain autoimmune and demyelinating manifestations induced by herpes virus. The association of multiphasic disseminated encephalomyelitis triggered by herpes virus in a patient with TLR3 deficiency has not been previously reported in the literature.

Suicidal ideation, anxiety, and depression in patients with multiple sclerosis

ABSTRACT Psychiatric disorders frequently occur in patients with multiple sclerosis (MS); however, limited reports are available on these comorbidities. We aimed to investigate the relationships among MS, anxiety, depression, and suicidal ideation. Methods: One hundred and thirty two patients with relapsing-remitting MS were evaluated using the Expanded Disability Status Scale, Beck Depression Inventory-II (BDI-II), Beck Scale for Suicide Ideation (BSI), and Hospital Anxiety and Depression Scale. Results: A hierarchical regression analysis was performed to evaluate the variables. The regression equation significantly predicted the BSI score (R2 = 0.306; adjusted R2 = 0.273; F (9, 125) = 9.18; p < 0.0005), and the BDI-II score was the only variable that contributed significantly to this model (p < 0.0005). Conclusions: A high prevalence of depression and anxiety, and a higher rate of suicidal ideation were identified in MS patients compared to the general population. The presence of depressive symptoms appeared to have a direct influence on the risk of suicide.

The cerebrospinal fluid in multiple sclerosis: far beyond the bands

The cerebrospinal fluid analysis has been employed for supporting multiple sclerosis diagnosis and ruling out the differential diagnoses. The most classical findings reflect the inflammatory nature of the disease, including mild pleocytosis, mild protein increase, intrathecal synthesis of immunoglobulin G, and, most typically, the presence of oligoclonal bands. In recent years, new biomarkers have emerged in the context of multiple sclerosis. The search for new biomarkers reflect the need of a better evaluation of disease activity, disease progression, and treatment efficiency. A more refined evaluation of disease and therapy status can contribute to better therapeutic choices, particularly in escalation of therapies. This is very relevant taking into account the availability of a greater number of drugs for multiple sclerosis treatment in recent years. In this review, we critically evaluate the current literature regarding the most important cerebrospinal fluid biomarkers in multiple sclerosis. The determination of biomarkers levels, such as chemokine ligand 13, fetuin A, and mainly light neurofilament has shown promising results in the evaluation of this disease, providing information that along with clinical and neuroimaging data may contribute to better therapeutic decisions.

Characterization of the first symptoms of multiple sclerosis in a Brazilian center: cross-sectional study

CONTEXT AND OBJECTIVE:

Multiple sclerosis (MS) is a chronic, immune-mediated and degenerative central nervous system (CNS) disease with well-established diagnostic criteria. Treatment can modify the course of the disease. The objective of this study was to describe the initial symptoms of multiple sclerosis in a Brazilian medical center.

DESIGN AND SETTING:

Descriptive study, conducted in a Brazilian reference center for multiple sclerosis treatment.

METHODS:

Data on 299 patients with confirmed diagnoses of MS were included in the study. Their medical files were evaluated and the data were analyzed.

RESULTS:

The most common symptom involved the cranial nerves (50.83%) and unifocal manifestation was presented by the majority of this population (73.91%). The mean time between the first symptom and the diagnosis was 2.84 years. Unifocal symptoms correlated with longer time taken to establish the diagnosis, with an average of 3.20 years, while for multifocal symptoms the average time taken for the diagnosis was 1.85 years. Unifocal onset was related to greater diagnostic difficulty.

CONCLUSIONS:

MS is a heterogeneous disease and its initial clinical manifestation is very variable.

Olfactory alterations in patients with multiple sclerosis

ABSTRACT This cross-sectional study involves 100 multiple sclerosis (MS) and 100 non-MS patients, under the age of 60 years old, with nasal obstruction, traumatic brain injury, previous rhinoplasty or neurosurgery, and so forth. Objective To assess olfactory function using the Connecticut test and verify correlations between olfactory alteration, disease duration and the Expanded Disability Status Scale (EDSS). Methods One hundred MS patients and 100 healthy control patients responded to a questionnaire. Those with olfactory alteration underwent a facial CT to exclude other causes. Results Thirty-two percent of patients showed alterations, compared with 3% in the healthy control group. Patients having EDSS above 4, showed a 5.2-times increased risk of dysfunction. Patients over 38 years of age have a 2.2-times increased risk over younger patients. Conclusions Because MS patients are likely to experience olfactory alterations, this study is a useful tool in follow-up care, although more studies are necessary to evaluate the correlations in MS evolution.

Polyomavirus detection in multiple sclerosis patients under natalizumab therapy: Profile and frequency of urinary shedding

Patients undergoing Natalizumab (NTZ) therapy are at risk of progressive multifocal leukoencephalopathy (PML). Besides John Cunningham virus (JCV), BK polyomavirus might represent an additional concern for such patients since it can also infect CNS cells. Currently, data regarding the presence of anti-JCV antibodies added to previous immunosuppressive therapy and prolonged NTZ therapy has been used to classify patients at risk of developing PML. Here, we investigated the profile shedding of JCV and BKV in multiple sclerosis (MS) patients during treatment with NTZ. Serial blood and urine samples from 97 MS patients receiving either NTZ or β-interferon were investigated for polyomavirus shedding. While all blood samples tested negative, 36% of the patients shed polyomavirus in the urine in at least one time point. From these, 21.7%, 9.3%, and 5.1% shed JCV, BKV, and both polyomavirus, respectively. No difference was observed between the rates of urinary shedding of patients treated with NTZ (38.9%) and patients treated with other drugs (34.5%), also no PML event was diagnosed during the follow-up. Therefore, urinary shedding might not be interfered by therapy condition. In our study, we also observed 14/27 (52%) of anti-JCV antibodies prevalence, and nearly half of them (42%) did not present any event of urinary shedding during the follow-up. J. Med. Virol. 89:528-534, 2017. © 2016 Wiley Periodicals, Inc.

Trigeminal involvement in multiple sclerosis: magnetic resonance imaging findings with clinical correlation in a series of patients

Trigeminal involvement detected by magnetic resonance imaging (MRI) in multiple sclerosis (MS) patients is usually associated with trigeminal neuralgia (TN) or painless paraesthesia in the trigeminal distribution. Our aim is to review the incidence of trigeminal involvement on MRI in a series of patients with MS at our institution, with further clinical correlation. We reviewed MRI scans of 275 MS patients for the presence of gadolinium enhancement on postcontrast T1-weighted images, anatomical and signal abnormalities on different sequences at the pontine trigeminal root entry zone (REZ) and in the cisternal portion of the nerves. We observed enhancement in the cisternal portion of the nerves and signal abnormalities (with or without enhancement) at the pontine trigeminal REZ in 8 (2.9%) patients, and enhancement was bilateral in 6 (75%) of those. Despite the inflammatory activity, none of them had TN and 3 (37.5%) had only painless paraesthesias in the correspondent V3 distribution. We also found a marked trigeminal hypertrophy in 2 (25%) patients, both with a longer period of disease. Our results confirm a high and clinically silent incidence of trigeminal involvement in MS patients, and suggest a simultaneous role of the central and peripheral type of myelin in trigeminal demyelination.

Validation and cross-cultural adaptation of sexual dysfunction modified scale in multiple sclerosis for Brazilian population

Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system (CNS). These patients suffer from various comorbidities, including sexual dysfunction (SD). The lesions of MS may affect regions of the CNS along the pathway of sexual response. The Multiple Sclerosis Intimacy and Sexuality Questionnaire-19 (MSISQ-19) is a scale that assesses sexual dysfunction. Adapt and validate the MSISQ-19 to Brazilian patients with MS. 204 individuals were evaluated, 134 patients with MS and 70 healthy persons for the control group. It was determined reproducibility, validity, internal consistency and sensitivity of the MSISQ-19-BR. Among patients with MS, 54.3% of male and 71.7% of female presented some kind of SD. In the control group the results were 12.5% and 19.5%, respectively. The MSISQ-19-BR is reproducible, reliable and valid for the Brazilian population and may be used as a tool for assessing the impact of sexual dysfunction in patients with MS.

Validation survey of the impact of urinary incontinence (IIQ-7) and inventory of distress urogenital (UDI-6) - the short scales - in patients with multiple sclerosis

Cross-cultural adaptation and validation of the Impact Questionnaire of Urinary Incontinence (IIQ-7) and Urogenital Distress Inventory (UDI-6) - short scale - in the Brazilian population with multiple sclerosis. The IIQ-7 and UDI-6 were translated into Portuguese, called IIQ-7-BR and UDI-6-BR. The questionnaires were administered in 211 individuals selected randomly. Of these, 140 had MS according to McDonald criteria and 71 were included in the control group. In both questionnaires, the Cronbach's alpha coefficient was above 0.7. The IIQ-7-BR showed 94.31% concordance between the evaluated studies and UDI-6-BR, 93.33%. Thus, the instruments of this study were presented according to the standards proposed by the Instrument Review Criteria, reliability, validity and sensitivity, maintaining the original scales characteristics.

Multiple sclerosis and herpesvirus interaction

Multiple sclerosis is the most common autoimmune inflammatory demyelinating disease of the central nervous system, and its etiology is believed to have both genetic and environmental components. Several viruses have already been implicated as triggers and there are several studies that implicate members of the Herpesviridae family in the pathogenesis of MS. The most important characteristic of these viruses is that they have periods of latency and exacerbations within their biological sanctuary, the central nervous system. The Epstein-Barr, cytomegalovirus, human herpesvirus 6 and human herpesvirus 7 viruses are the members that are most studied as being possible triggers of multiple sclerosis. According to evidence in the literature, the herpesvirus family is strongly involved in the pathogenesis of this disease, but it is unlikely that they are the only component responsible for its development. There are probably multiple triggers and more studies are necessary to investigate and define these interactions.

Central nervous system infectious diseases mimicking multiple sclerosis: recognizing distinguishable features using MRI

The current diagnostic criteria for multiple sclerosis (MS) confirm the relevant role of magnetic resonance imaging (MRI), supporting the possibility of characterizing the dissemination in space (DIS) and the dissemination in time (DIT) in a single scan. To maintain the specificity of these criteria, it is necessary to determine whether T2/FLAIR visible lesions and the gadolinium enhancement can be attributed to diseases that mimic MS. Several diseases are included in the MS differential diagnosis list, including diseases with exacerbation, remitting periods and numerous treatable infectious diseases, which can mimic the MRI features of MS. We discuss the most relevant imaging features in several infectious diseases that resemble MS and examine the primary spatial distributions of lesions and the gadolinium enhancement patterns related to MS. Recognizing imaging "red flags" can be useful for the proper diagnostic evaluation of suspected cases of MS, facilitating the correct differential diagnosis by assessing the combined clinical, laboratory and MR imaging information.

Medication withdrawal may be an option for a select group of patients in relapsing-remitting multiple sclerosis

This article describes the clinical and radiological evolution of a stable group of patients with relapsing-remitting multiple sclerosis that had their disease-modifying therapy (DMT) withdrawn. Forty patients, which had made continuous use of one immunomodulator and had remained free of disease for at least 5 years, had their DMT withdrawn and were observed from 13 to 86 months. Out of the followed patients, 4 (10%) patients presented with new attacks. In addition to these patients, 2 (5%) patients had new lesions revealed by magnetic resonance imaging that did not correspond to clinical attacks. Despite these results, the difficult decision to withdraw medication requires careful analysis. Withdrawal, however, should not be viewed as simply the suspension of treatment because these patients should be evaluated periodically, and the immunomodulators should be readily reintroduced if new attacks occur. Nonetheless, medication withdrawal is an option for a select group of patients.

Oropharyngeal dysphagia in patients with multiple sclerosis: do the disease classification scales reflect dysphagia severity?

Multiple sclerosis is a neurological disease that involves swallowing disorders. Many studies have shown an association between neurological and swallowing performance, but results have been conflicting.

Objective

To identify the frequency of dysphagia in patients with multiple sclerosis and neurological indicators that can represent the performance of swallowing.

Method

In this study (cross-sectional) 120 Multiple Sclerosis patients underwent Functional Assessment of Swallowing by flexible nasal-pharyngo-laryngoscopy and the results were compared with the scores of the rating scales: (Clinical Evolving Forms of Disease, Functional Disability Scale for and Scale Systems Extended Functional Disability [Kurtzke Expanded Disability Status Scale]).

Results

Dysphagia was found in 90% of patients. Among the clinical forms of the disease, the progressive forms (primary progressive and secondary progressive) were more frequently associated with severe dysphagia, while the relapsing-remitting form presented more often mild and moderate dysphagia. Regarding the Disability Scale for Functional Systems, cerebellar function, brainstem function and mental health were associated with dysphagia, especially in the severe form. Regarding the Extended Functional Disability Scale, higher scores were associated with severe dysphagia.

Conclusion

Dysphagia is common in MS patients, especially in those with greater impairment of neurological functions.

Cross-cultural adaptation and validation of the 12-item Multiple Sclerosis Walking Scale (MSWS-12) for the Brazilian population

Gait impairment is reported by 85% of patients with multiple sclerosis (MS) as main complaint. In 2003, Hobart et al. developed a scale for walking known as The 12-item Multiple Sclerosis Walking Scale (MSWS-12), which combines the perspectives of patients with psychometric methods.

OBJECTIVE

This study aimed to cross-culturally adapt and validate the MSWS-12 for the Brazilian population with MS.

METHODS

This study included 116 individuals diagnosed with MS, in accordance with McDonald's criteria. The steps of the adaptation process included translation, back-translation, review by an expert committee and pretesting. A test and retest of MSWS-12/BR was made for validation, with comparison with another scale (MSIS-29/BR) and another test (T25FW).

RESULTS

The Brazilian version of MSWS-12/BR was shown to be similar to the original. The results indicate that MSWS-12/BR is a reliable and reproducible scale.

CONCLUSIONS

MSWS-12/BR has been adapted and validated, and it is a reliable tool for the Brazilian population.

Clinical predictors of response to immunomodulators for multiple sclerosis

OBJECTIVES: To determine, based on clinical criteria, the proportion of multiple sclerosis (MS) patients responsive to immunomodulators (RI) and nonresponsive to immunomodulators (NRI), and to ascertain whether clinical and epidemiological data differs between RI and NRI patient groups. METHODS: Patients were assessed on rate of exarcerbations per year, for the period before and after commencement of treatment. The RI and NRI groups were compared for several clinical and epidemiological characteristics. DISCUSSION AND CONCLUSION: A total of 31.4% of the patients were nonresponders to the immunomodulatory treatment. The main predictors of immunomodulatory response were early diagnostic and commencement of therapy and high rate of annual exacerbations prior to treatment. Given the arsenal of medication options available for MS management, screening potential candidates for different therapeutic approaches are critical to optimize evolution of patients with the disease.

Incidental demyelinating inflammatory lesions in asymptomatic patients: a Brazilian cohort with radiologically isolated syndrome and a critical review of current literature

Despite the definition of specific diagnostic criteria to identify radiologically isolated syndrome (RIS) suggestive of multiple sclerosis, its natural history remains incompletely understood. We retrospectively analyzed a Brazilian cohort of 12 patients to clarify their features and to emphasize the role of imaging predictors in clinical conversion. We demonstrated that, although some individuals did not exhibit progression over a lengthy follow-up period (16.7%), most patients will progress clinically or radiologically in the initial years of the follow-up (83.3%). Infratentorial and spinal cord involvement, as well as the total number of lesions, were more relevant predictors of progression than gadolinium enhancement. Further studies remain necessary to define the risk of conversion in males and to clarify the cognitive abilities of RIS patients. This study may provide an improved understanding of the natural course and evolution of incidental magnetic resonance imaging lesions, and further assists with the management of RIS in clinical practice.

Validation of the "Six Step Spot Test" for gait among patients with multiple sclerosis in Brazil

The clinical manifestations of multiple sclerosis (MS) are variable among patients, and the course of disease is not linear. Different symptoms are presented, with gradual accumulation of disability. These variations are difficult to quantify in clinical practice, and several studies have attempted to create instruments capable of measuring these disabilities. The Six Step Spot Test (SSST) was developed for quantitative evaluation of the lower limbs (LL) over time. Performance in this test reflects the complexity of sensory-motor function, including LL strength, spasticity, coordination and balance, going beyond vision and cognition. The aim of the present study was to validate the SSST in a population of MS patients in Brazil. This prospective study included 75 patients with MS, with EDSS 0 to 6.5 in the study group. Ninety-one healthy subjects were randomly selected for the control group. The results showed that the groups were similar, and that the SSST is a reliable and reproducible test. According to the statistical analysis on the data in this study, the SSST is a valid, reliable and reproducible tool for use in the Brazilian MS patient population.

Psychiatric disorders in multiple sclerosis patients

Multiple sclerosis (MS) is a demyelinating disease showing variable clinical presentation. Optic neuritis is the most common symptom, followed by motor and sensitive manifestations. It is known that this disease may be related to several psychiatric disorders, especially depression. In this study we will discribe 5 cases of MS patients harboring psychiatric disorder related or unchained by the disease itself.

[Multiple sclerosis: cross-cultural adaptation and validation of the modified fatigue impact scale]

OBJECTIVE

The aim of this study is a cross-cultural adaptation and validation of the modified fatigue impact scale for Portuguese (MFIS-BR).

METHOD

The MFIS was translated to Portuguese and re-translated to English. Two pilot studies had been carried through to obtain the MFIS-BR, which was applied to 57 consecutive stable MS patients and 45 healthy controls. The retest was applied 30 days later.

RESULTS

In analyzing the statistics the internal consistency reability was similar to the original scale (0.74-0.86). The MFIS-BR showed ability to identify the different groups. Concerning the reliability the interclass correlation coefficient showed an excellent agreement (0.264-1.0).

CONCLUSION

The MFIS-BR fills the criteria of applicability, sensibility which are similar to the original version.

Immunomodulator therapy migration in relapsing remitting multiple sclerosis: a study of 152 cases

BACKGROUND: Since 1997, immunological modulators have been used for treatment of Relapsing Remitting Multiple Sclerosis (RRMS) in the Multiple Sclerosis Attendance and Treatment Center (CATEM) with significant alterations in this disease natural history. AIM: To add data on the experience of CATEM for the treatment of RRMS patients that had immunomodulators. METHOD: RRMS patients that received continuously immunomodulator drugs were evaluated on adherence, migration, withdrawal and progression rates. The patients were divided in three groups by the period of immunomodulators intake. RESULTS: There were registered in Group 1 withdrawal in 98 patients (25%) and adherence in 292 cases (74%); Group 2 interruption of therapy in 140 patients, 92 (31%) due to progression for PSMS, 14 (5%) for pregnancy, withdrawal in 34 (11%), adherence in 88%; Group 3 progression in 41 (26%), pregnancy in 3 (2%) withdrawal in 42 (27%) and adherence in 72%. The migration rate was about one third (31.57%) and the principal cause was therapeutic failure; the mean migrating time was 0.5-2.5 years in group 3. CONCLUSION: Immunomodulatory treatment for RRMS patients may have significant levels of failure and side effects; the adherence was compatible with the international literature.

Reabilitação vestibular em pacientes com esclerose múltipla remitente-recorrente

A esclerose múltipla (EM) é doença desmielinizante, inflamatória, que acomete a substância branca do sistema nervoso central, e sensações vestibulares anormais (vertigem, desequilíbrio) são freqüentes. A reabilitação vestibular (RV) é determinada por mecanismos de adaptações, substituições e compensações neurais. Este estudo avaliou a melhora da vertigem central ou periférica em pacientes com EM remitente-recorrente submetidos à RV (exercícios de Cawthorne-Cooksey), através da escala de Berg e Dizziness Handicap Inventory (DHI). Nesta amostra de 4 casos a RV, realizada em um período de 2 meses, demonstrou a melhora em 3 pacientes avaliados pela escala de Berg e em 2 pacientes quando avaliados pela DHI.

Attention impairment associated with relapsing-remitting multiple sclerosis patients with mild incapacity

Neuropsychological studies have consistently reported cognitive dysfunctions associated with multiple sclerosis. One-hundred fifteen subjects with relapsing-remitting multiple sclerosis (RRMS) were compared with forty health controls according to a neuropsychological test battery, which included digit span, trail making, cancellation and stroop test. Both groups were matched for age, sex and educational level. Subjects with RRMS had a worse performance the speed of response. Subjects with RRMS spent more time to complete the test in either sections A (p=0.001) or B (p=0.001), although there was no significant difference in terms of number of errors. The total time required to finish the Stroop test was higher for subjects with RRMS (p<0.001), being the time difference between groups significant at trial 4 (p<0.001). Attention impairment in subjects with RRMS is related to slowed central processing, which may be affected in all stages, including impairment of automatic and controlled processing of information and in the motor program.

Effect of the treatment with methylprednisolone on the cerebrospinal fluid and serum levels of CCL2 and CXCL10 chemokines in patients with active multiple sclerosis

BACKGROUND

Several experimental and human studies suggest that the chemokines CCL2 and CXCL10 may play a role in the pathogenesis of multiple sclerosis (MS). Here, we evaluated the effect of intravenous methylprednisolone (IVMP) therapy on the levels of CCL2 and CXCL10 in the cerebrospinal fluid (CSF) and serum of patients with active MS.

METHODS

Serum and CSF samples were obtained from 14 patients with active relapsing-remitting MS (age +/- SD years, 37.0 +/- 8.1; M/F, 6/8) and age- and gender-matched control subjects. All patients were submitted to IVMP treatment (500 mg daily for 5 days). Blood and CSF sampling were performed at admission, i.e. before treatment (day 0), at the end of the treatment (day 6) and 30 days after treatment (day 30). The clinical status of MS patients was also assessed. CCL2 and CXCL10 were measured by enzyme-linked immunosorbent assay.

RESULTS

Multiple sclerosis patients had lower CCL2 and higher CXCL10 in CSF when compared with control subjetcs. After treatment with methylprednisolone, MS patients showed clinical improvement and the CSF concentrations of CCL2 and CXCL10 modified toward normal values.

CONCLUSIONS

The clinical improvement of active MS following the treatment with methylprednisolone was associated with the modification of CSF levels of CCL2 and CXCL10, suggesting that these chemokines may be useful markers of response to treatment and relapses in MS patients.

[Fatigability evaluation on multiple sclerosis patients by using a hand held dynamometer]

Fatigue is one of the most common disabling symptoms in multiple sclerosis (MS). The aim of this study was to evaluate the fatigability on patients with MS by the application of hand grip isotonic and isometric exercises with dynamometer. As results the fatigability, the isometric strength and time were statistically similar in the control group and in MS. We conclude that although fatigue is a frequent subjective complaint on MS, the fatigability and the recover after exercises seems to be normal.

Immunomodulatory treatment in multiple sclerosis: experience at a Brazilian center with 390 patients

Since 1993 the Federal Drug Administration approved the use of immunomodulatory therapy in multiple sclerosis (MS), modifying the natural course of disease, as demonstrate our experience in treatment of MS patients at the MS Treatment Center (CATEM). OBJECTIVE: To evaluate patient behavior using immunomodulatory therapy for a period of five years treatment. METHOD: We selected 390 patients in CATEM with relapsing-remitting MS (RRMS) and secondary progressive MS (SPMS) with relapses. RESULTS: At initial treatment 292 (61.5%) patients presented RRMS, 98 (20.6%) SPMS with relapses, 27 SPMS (5.6%) and 58 (12.1%) primary progressive MS (PPMS). In RRMS 182 (62.5%) used the interferon beta 1a SC, 15 (5.2%) interferon beta 1a IM, 85 (29%) interferon beta 1b and 10 (3.3%) glatiramer acetate. In SPMS 63 (64.3%) used interferon beta 1a SC, 4 (4.1%) interferon beta 1a IM and 31 (31.4%) interferon beta 1b. We observed that in this period 195 (50%) migrated between drugs, 35 (9%) gave up therapy and 160 (41%) continued the initial therapy. CONCLUSION: Stopping the immunomodulatory therapy emerges as a problem in the second year of treatment and it can be a subset of interferon non responsive or development of neutralizing antibodies.

Sinais e sintomas associados a alterações otoneurológicas diagnoticadas ao exame vestibular computadorizado em pacientes com esclerose múltipla

OBJETIVO: Descrever os principais sintomas e sinais ao exame vestibular computadorizado em pacientes com diagnóstico de esclerose múltipla. MÉTODO:Foram examinados 30 pacientes com diagnóstico de esclerose múltipla. Analisaram-se os dados relativos à sintomatologia e achados ao exame vestibular computadorizado realizado no ambulatório de otoneurologia da Irmandade Santa Casa de Misericórdia de São Paulo, em 2003. RESULTADOS: Em relação aos sintomas relatados, observamos desequilíbrio (60%), formigamento de extremidades (43,3%), vertigem (40%), cefaléia e ansiedade (36,7%), zumbido (30%), depressão (26,7%). Ao exame vestibular encontramos alterações do nistagmo de posicionamento (6,7%), nistagmo espontâneo de olhos fechados (30%), nistagmo semi-espontâneo (13,3%), rastreio pendular (3,3%) e prova calórica (63,3%). Na conclusão do exame tivemos prevalência de síndrome vestibular periférica irritativa (60%) e síndrome central (13,4%). CONCLUÇÃO: Concluimos que a realização do exame otoneurológico torna-se imprescindível nos pacientes com esclerose múltipla devido a elevada prevalência de alterações à vectonistagmografia computadorizada e elevada prevalência de sintomas otoneurológicos.

[Ethical issues in multiple sclerosis under physicians and patients point of view]

Multiple sclerosis (MS) is a neurologic disorder that mostly affects young adults and can usually evolute to physical disability. Thus, caring patients with MS brings many ethic questions for the physician.

OBJECTIVE

To identify physicians and patients' perceptions about the illness and so improve doctor-patient relationship.

METHOD

It was made two different questionnaires, one for patients and another for physicians, 103 patients and 44 physicians answered them.

RESULTS

96.1% of patients knew their diagnosis, all others would like to know it. From those, 74.7% thought that that way it was disclosured was correct and 90.9% said that the doctor should tell us it. The worst symptoms described were fatigue (29.1%) and motor deficits (28.1%). By other side, 68% of patients told they suffered because of the illness. The most important reason for doctors to tell the diagnosis to the patients was to improve adherence to treatment (56.8%). A familiar present at this moment was demanded for 54.6% of doctors. When asked about orientations in a pregnancy, 50% of physicians did not answer correctly. Finally, 50% of physicians were against complementary and alternative therapies.

CONCLUSION

Patients want to know their diagnosis and doctors should tell them in the most adequate moment and give more information. A debate about palliative care is also necessary.

[Validation of the functional assessment of multiple sclerosis quality of life instrument in a Portuguese language]

The objective of the present study was to translate, to do cultural equivalence and validation of the Functional Assessment of Multiple Sclerosis quality of life instrument (FAMS) to Portuguese. The database analyzed is longitudinal, with 143 patients with clinically defined multiple sclerosis (MS). The validity of the scale was established by correlating total FAMS scores and sub-scales scores to EDSS and EAN. The internal consistency reliability were similar to those of the original FAMS. All sub-scales correlated with each other (0.35 to 0.71). Total FAMS score correlated significantly with EDSS, and EAN. All sub-scales correlated to EDSS. Kendall's Tau coefficient, showed significant associations between basal and first visit. Responsiveness was investigated considering two groups: patients with EDSS < 3.5 and with EDSS > 3.5. There was significantly higher score in the group with light EDSS when compared to the group of patients with moderate EDSS. One can conclude, based on this retrospective study that FAMS instrument translated to Brazilian Portuguese can be considered reliable, responsive and content valid.

[Neural conduction in hand nerves and the physiological factor of age]

Many researchers have established the influence of physiological factors as age, for the parameters of the study of the motor and sensitive conduction. The objective of this study was to analyze the influence of the variable age in the study of the motor and sensitive nervous conduction of the median and ulnar nerves. The data were collected from 92 volunteers: 61 women and 31 men. Their age was from 13 to 74 years old, with a mean of 36.3 years. Most of them were employees at Santa Casa de São Paulo. It was observed that a reduction in the velocity of sensitive and motor nervous conduction takes place with the age. This reduction is associated with a reduction in the amplitude of the evoked potential.

Depressão na esclerose multipla forma remitente-recorrente

A possibilidade de correlação entre depressão e esclerose múltipla (EM) é conhecida há muitos anos, porém os estudos de prevalência não são conclusivos. No nosso meio a prevalência deste sintoma na EM permanece desconhecida. O objetivo deste estudo é verificar a prevalência da depressão em pacientes com EM, estudando a sua correlação com a incapacidade funcional, o sexo, a idade e o tempo de doença. Foram avaliados 84 pacientes com EM remitente-recorrente (EMRR). A depressão foi avaliada através da Escala de Beck e da Escala para Ansiedade e Depressão (HAD), e a incapacidade funcional pela Escala de Incapacidade Funcional Expandida (EDSS). A depressão estava presente em 17,9% e a ansiedade em 34,5% dos pacientes com EMRR. Os maiores escores das escalas de depressão correlacionaram-se com maior incapacidade funcional (p=0,0002), porém não estão associados ao tempo de doença, ao sexo ou a idade dos pacientes. Nossos dados indicam que a depressão é frequente nos pacientes com EM e sugerem haver correlação entre a depressão e a incapacidade funcional.

[Historical aspects of multiple sclerosis]

INTRODUCTION

Multiple sclerosis (MS) is one of the most common diseases of the central nervous system (CNS) in young adults. MS is the most common disorder of the central nervous system in young people living in temperate climate regions. Although a few references to possible cases of the disease come from the xiii century, its scientific observation and systematic study only started in the late xix century.

DEVELOPMENT

Robert Carswell e Jean Cruveilhier were the first investigators to document the pathological lesions while the clinical picture was first studied by Charcot. In spite of a huge number of infectious agents has been proposed for the etiology of MS and a genetic susceptibility trait recently defined, the ultimate cause of the disease remains to be determined. The development of diagnostic criteria sets, clinical disability scales and image methods in the latter half of the last century has provided investigators with useful research tools allowing unprecedented advances. In the last 30 years ACTH and corticosteroids have been employed as treatment for MS relapses. Starting in 1993 a new class of drugs called disease modifying agents, such as interferon beta and more recently glatiramer acetate, was introduced with encouraging results.

CONCLUSIONS

MS is postulated to be a cell mediated autoimmune disease directed against CNS myelin components and characterized by inflammation and chronic demyelination. This paper is a review of the principal most significant events in the search for knowledge of the disease in the world.

[Box and block test of manual dexterity in normal subjects and in patients with multiple sclerosis]

Recently new disease-modifying treatments for multiple sclerosis (MS) were introduced which can change the natural course of the disease. In clinical trials with these new agents the Expanded Disability Status Scale (EDSS) is often used as a primary outcome instrument to measure neurological impairment and disability. A number of limitations have been identified when using the EDSS, some of wich are because the EDSS is an ordinal scale that is heavily biased to locomotor function. In this study we applied the box and block test of manual dexterity in normal subjects and relapsing-remitting MS patients. The results were that 64.8% of the female and 80.7% of the male patients had significant changes on this task compared with normal subjects, and as this test is easily applied and is sensitive in detecting upper extremity functional ability, we recommend its use in clinical trials to evaluate new drugs in MS patients.

The prevalence of multiple sclerosis in the city of São Paulo, Brazil, 1997

July 1, 1997 was stipulated as the day for estimating the prevalence of multiple sclerosis within the city of São Paulo. The patients were identified via various sources, including associated universities and magnetic resonance services of the city of São Paulo. The area covered by the study has a population of 9,380,000, mainly white and of European origin, with a large number of immigrants from Spain and Portugal. The patients were classified in accordance with the criteria of Poser et al. (1983), and only those with defined multiple sclerosis were registered. The study gave a prevalence of 15.0/10(5) inhabitants, or three times the value obtained in a similar study in 1990. This increase reveals the larger number of cases encompassed by the study, and is attributed to the use of more detailed recording methods, improvements in diagnosis, and better conditions for treatment.

Pattern of cytokine secretion by peripheral blood cells of patients with multiple sclerosis in Brazil

Autoimmune T cells play a key role as regulators and effectors of organ-specific autoimmune disease. In multiple sclerosis (MS), activated T cells specific for myelin components produce a plethora of inflammatory cytokines and mediators that contribute to myelin damage. The production of proinflammatory and regulatory cytokines by peripheral blood cells from patients with active and stable MS and healthy controls were examined. The results show that TNF alpha production was somewhat elevated in active MS with no significant increase in the level IFN gamma, whereas in the chronic phase the anti-inflammatory cytokines IL-10 and TGF beta increased, accompanied by a reduction in IFN gamma when stimulated by myelin basic protein. Multiple Sclerosis (2000) 6 293 - 299

[Recommendations for the use of immunomodulatory drugs in multiple sclerosis: the BCTRIMS consensus] [Brazilian Committee for Treatment and Research in Multiple Sclerosis]

After brief considerations about clinical course and diagnosis in multiple sclerosis, the members of the BCTRIMS present some recommendations for the use of the immunomodulatory drugs in the treatment of this disease.

[Comparative analysis of 2 clinical scales for clinical evaluation in multiple sclerosis: review of 302 cases]

Many neurologic scales have been used for clinical evaluation of multiple sclerosis, but there is no consensus about which one is the most appropriate to assess evolution and point to a new relapse. The Expanded Disability Status Scale (EDSS) has been the most commonly used. We analyse the reliability of two scales: the EDSS and Neurologic Rating Scale (NRS) in 302 multiple sclerosis patients. It is shown that NRS is a more sensitive scale than EDSS to disclose clinical changes (22.1% of cases). Changes in NRS were more evident in patients with EDSS 3.0 and 3.5. We comment on these findings and suggest that both scales should be employed in multiple sclerosis treatment trials.

[Fatigue and multiple sclerosis: preliminary study of 15 patients with self-reported scales]

Fatigue is a common and disabiling symptom in multiple sclerosis but is poorly understood. Self-report measures are designed to capture the patient's subjective sense of fatigue. We applied three scales in 15 patients with MS. Nine of them reported fatigue. The scores were high in all of these patients. We conclude that these scales must be used in assemble, to evaluate this symptom. Also, fatigue a very important symptom in multiple sclerosis patients.

[Multiple sclerosis: descriptive study of its clinical forms in 302 cases]

Multiple sclerosis (MS) is one of the most common causes of chronic neurologic disability in young adults. We evaluate, through retrospective study, the epidemiological characteristics, the manifestations ways, the clinical manifestations, the evolution and the level of physical disability of MS in 302 patients. The average patients age was 37.7 and the relation between genders was 3.13F:1M. The average age at the beginning of MS was 29.6; 283 patients were white (94%), 15 patients were black (5%) and 4 patients were yellow; 220 patients (72%) presented relapsing-remmiting clinical form; 82 patients (28%) presented the progressive form (50% secondary form and 50% primarily progressive form). The most common initial symptoms were sensitive (31.7%) and optical (26.8%). The most common evolutive symptoms were pyramidal (72.5%) and of the spinal cord (64.9%). The average of the final EDSS was 3.37 and final NRS was 85.17. The index of the annual outbreak was 0.45. Our findings coincide to the ones in the worldwide literature, however it is important to point out that 60 patients (19.8%) presented benign MS of prognostic value.

[Interferon beta 1-a in multiple sclerosis: 1-year experience in 62 patients]

We report the results of a trial of interferon beta 1-a in 62 ambulatory patients with relapsing-remitting multiple sclerosis. Entry criteria included EDSS of 0 to 5.5 and at least two exacerbations in the previous 2 years. The patients received 3 million international units by subcutaneous injections three times a week. The end points were differences in exacerbation rate and treatment effect on disease progression. The annual exacerbation rate for patients that did not take the interferon beta 1-a was 1.32 and for the patients under medication 0.63. The EDSS score in patients that did not take the mediaction was 4.7 and 2.0 for the patients with interferon beta 1-a. Interferon beta 1-a was well tolerated and 85% of patients completed 1 year treatment.

"Gliomatosis cerebri" simulating an acute diffuse encephalomyelitis. Case report

Neuroradiologic, neuropathologic and immunohistochemical features are reported in a young man with a impairment of the central nervous system mimicking an acute diffuse encephalomyelitis. A white male, 17 years old, healthy till 4 months before, when developed a right hemiparesis and after 2 months a bilateral hemiparesis with a progressive impairment of several cranial nerves. Magnetic resonance imaging showed multiple lesions without a mass effect that suggested myelin loss. He remained unconscious for almost one month before dying of pneumonia. The neuropathologic examination showed a heavy brain (1505 g) with herniations and a large right midbrain. There were several soft and pink areas mainly at the right midbrain, left cerebellum and in the white matter of the left cerebral hemisphere. The histopathologic sections showed diffuse blastomatous proliferation without total replacement or destruction of the original tissue. The tumor cells had astrocytic, oligodendrocytic and spongioblastic phenotypes, some of them with a GFAP-positive reactivity. There were focal anaplastic changes. The diagnosis of "gliomatosis cerebri" was only possible by the autopsy.

[Multiple sclerosis simulating cerebral tumor: report of a case with histopathological confirmation]

A 41 year old woman with subacute onset of moderate and progressive right hemiparesis showed on the MRI a unilateral white matter lesion on the left temporoparietal region and a small lesion on the right frontal region. The CSF was normal. Because possible diagnosis of tumor or abscess, the patient underwent a cerebral biopsy. The histological result was of brain tissue with demyelination and reactive changes. The stains for viral etiology were negative.

[Multiple sclerosis: clinical analysis and development of 214 cases]

The authors report on a series of 214 cases of defined multiple sclerosis according to Poser et al. criteria. These cases were retrospectively selected by medical reports analysed from Santa Casa Medical School (São Paulo) and the private practice, from 1980 to 1993. The data were analysed as for sex, race, onset age of symptoms, onset symptoms, and evolutive symptoms. The results were compared to those found in other Brazilian series and in foreign series. This comparative analysis allows to verify similarities and differences among the several series, and the authors emphasize the necessity of multicentric studies in Brazil to assert with more details the multiple sclerosis profile in our country.

[Increase of interleukin-2 soluble receptors in multiple sclerosis: preliminary study in 26 patients]

Serum samples were analysed for interleukin-2 receptors levels (sIL-2R) in 26 patients with definite multiple sclerosis as defined by Poser and col. Three groups of patients form the basis of this study: group I, with 14 patients with clinical evidence of active disease; group II, with 12 patients with clinically stable multiple sclerosis; and group III, with 8 patients with other neurological diseases. Blood was collected by venipuncture and centrifuged. All samples were stored at -20 degrees C until testing. The assay used monoclonal antibodies against epitopes of interleukin-2 receptors. In the wells of a microtiter plate coated with anti-soluble interleukin-2 receptors (Immunotech SA) samples to be measured or standards are incubated in the presence of a second monoclonal antibody conjugated with alkaline phosphatase. The amount of bound enzyme-conjugate is measured by adding a chromogenic substrate. The intensity of the resulting colour is proportional to the sIL-2R concentration present in the sample. Increased serum levels of sIL-2R were found in 7 of 14 patients with active multiple sclerosis (50%), in only 1 of the 12 patients with clinically stable multiple sclerosis and in none of the patients with other neurological diseases.

Prevalence of multiple sclerosis in the city of São Paulo, Brazil, in 1990

A case register of multiple sclerosis (MS) was set up in the city of São Paulo, Brazil, situated at a latitude of 23-24 degrees south. Cases were notified by neurologists, neuroradiologists and by an association of patients with MS. Prevalence rate was 4.27 x 10(-5) (men: 2.89 x 10(-5); women: 5.59 x 10(-5)), with a preponderance of young adults. We discuss here whether these rates are artifact due to poor health care facilities, to poor notification and deficiencies in diagnosis, or whether these rates are really low.

[Multiple sclerosis: clinical and pathological study of a case]

We present a case with diagnosis of multiple sclerosis done on clinical criteria and proved by autopsy. The morphological aspects of the lesions are well known and often related in the literature. Our objective is to describe the first necropsy among 30500 done at Santa Casa de São Paulo in a patient with the disease. The morphological aspects in the CNS with the characteristic plaques in different grades of activity and the detection of immunoglobulins in these plaques confirm the pathogenic hypothesis about a disease immunologically mediated.