AUTOIMMUNE DISORDERS OF NERVOUS SYSTEM ABOUT ME

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1 AUTOIMMUNE DISORDERS OF NERVOUS SYSTEM KAISER PERMANENTE SHAHRAM GHARIBSHAHI, MD ABOUT ME Medical School IAU Tehran, Iran Internship United Health Services Johnson City, NY Residency Ohio State University Columbus, OH Fellowship, Neurophysiology Ohio State University Columbus, OH Fellowship, Sleep medicine Harvard Medical School Boston, MA Board certified, American Board of Neurology and Psychiatry Board certified, American Board of Sleep Medicine Employment: Panorama City, Kaiser Permanente 1

2 DISCLOSURE Financial disclosure 'Nothing to disclose' I do not have any financial relationship or received any financial and other support from commercial interests IMMUNE SYSTEM 2

3 IMMUNE SYSTEM Innate immune system Barriers Complement system Cellular barriers NK Cells (Natural Killer Cells) Adaptive immune system Lymphocytes T Cells B cells NERVOUS SYSTEM CNS (central nervous system) Brain Spinal Cord PNS (peripheral nervous system) Nerves outside of the brain and spinal cord Somatic sensory Autonomic Neuron Basic building block of the nervous system Neuromuscular junction Connects the nervous system to the muscular system 3

4 NERVOUS SYSTEM AUTOIMMUNE DISEASES OF NERVOUS SYSTEM Autoimmune disorders of myelin (Demyelinating disorders) 4

5 DEMYELINATING DISORDERS (CNS) Brain Optic Neuritis Multiple Sclerosis (MS) MS variants Neuromyelitis Optica Acute Disseminated Encephalomyelitis (ADEM) (Post-Infectious Encephalitis) Acute hemorrhagic leukoencephalitis Spinal cord Transverse myelitis OPTIC NEURITIS Inflammation of the optic nerve Cause: Autoimmune Inflammation of the optic nerve 5

6 OPTIC NEURITIS Symptoms Pain (worsened by eye movement) Vision loss Loss of color vision (desaturation to red) Flashing lights OPTIC NEURITIS Risk factors Age (15-40) Sex (F>M) Race (W>AA) Diagnosis History Exam Visual Acuity Ophthalmoscopy Pupillary light reaction test 6

7 OPTIC NEURITIS Ophthalmoscopy Pupillary light reaction test (afferent pupillary defect) OPTIC NEURITIS Tests Visual Evoked Response (VER) 7

8 OPTIC NEURITIS MRI Increased signal and enhancement of the optic nerve OPTIC NEURITIS Optical Coherence Tomography Blood test TFT ESR ANA ACE RPR 8

9 OPTIC NEURITIS Treatment Observation Steroid (PO vs. IV) Optic Neuritis Treatment Trial (ONTT) observation without steroid treatment versus intravenous (IV) steroid treatment showed no difference in ultimate visual outcome at the 5-year mark (Arnold AC. Evolving management of optic neuritis and multiple sclerosis. Am J Ophthalmol. Jun 2005;139(6):1101-8) Immune-mediated inflammatory disease that attacks myelinated axons in the CNS 9

10 Cause: (Unknown) Genetic Susceptibility (HLA-DRB1*15:01) Nongenetic trigger Viral infection Low Vit D Environmental factors Further away from equator = 1:2000 Close to equator = 1:20,000 First-degree relatives = 7 fold increased risk of MS (Familial risk of multiple sclerosis: a nationwide cohort study.am J Epidemiol: 2005 Oct 15;162(8): Epub 2005 Aug 24.) Risk factors Age: Sex: F>M Family history: First degree relatives Certain infections: EBV Race: Highest=White people(northern European descent) Lowest=Asian, African or Native American descent Climate: Temperate climates=southern Canada, northern United States, New Zealand, southeastern Australia and Europe. Certain autoimmune diseases: thyroid disease, DM 1, IBD Smoking 10

11 Chronic cerebrospinal venous insufficiency (CCSVI) Zamboni P, Galeotti R, Menegatti E, et al. Chronic cerebrospinal venous insufficiency in patients with multiple sclerosis. J Neurol Neurosurg Psychiatry. Apr 2009;80(4):392-9 Abnormal venous haemodynamics determined by extracranial multiple venous strictures of unknown origin 65 CDMS 235 Controls Internal jugular vein and azygous vein angioplasty had a positive effect on MS symptoms in patients with CCSVI Zamboni P, Galeotti R, Menegatti E, et al. A prospective openlabel study of endovascular treatment of chronic cerebrospinal venous insufficiency. J Vasc Surg. Dec 2009;50(6): e1-3 US Food and Drug Administration (FDA) has issued a warning FDA NEWS RELEASE For Immediate Release: May 10, 2012 Media Inquiries: Michelle Bolek, , Michelle.Bolek@fda.hhs.gov Consumer Inquiries: 888-INFO-FDA Because there is no reliable evidence from controlled clinical trials that this procedure is effective in treating MS, FDA encourages rigorously-conducted, properly-targeted research to evaluate the relationship between CCSVI and MS, said William Maisel, M.D., M.P.H., chief scientist and deputy director for science in the FDA s Center for Devices and Radiological Health. Patients are encouraged to discuss the potential risks and benefits of this procedure with a neurologist or other physician who is familiar with MS and CCSVI, including the CCSVI procedures and their outcomes. In February 2012, the FDA sent a warning letter to a sponsor/investigator who was conducting a clinical study of CCSVI treatment without the necessary approval ( The sponsor/investigator voluntarily closed the study. 11

12 Hepatitis B vaccine Anecdotal reports suggesting a connection between hepatitis B vaccination and MS CDC (Centers for Disease Control and Prevention. FAQs about Hepatitis B Vaccine (Hep B) and Multiple Sclerosis. Accessed 10/04/2010) weight of the available scientific evidence does not support the suggestion that hepatitis B vaccine causes or worsens MS ( National Multiple Sclerosis Society expert panel People with MS should not be denied access to healthpreserving and potentially-life saving vaccines because of their MS, and should follow the CDC guidelines for any given vaccine ( Symptoms Optic neuritis Stroke-like symptoms Spinal cord symptoms Fatigue depression Memory and cognitive issues Seizure Uhthoff's phenomenon Worsening of neurologic symptoms in when the body gets overheated Lhermitte s sign Sudden transient electric-like shocks extending down the spine triggered by flexing the head forward's sign 12

13 Types Progressive relapsing Secondary progressive Primary progressive Relapsing remitting Diagnosis Disseminated in time and space No diagnosis after the single symptomatic episode (Polman CH, Reingold SC, Banwell B, et al. Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria. Ann Neurol. Feb 2011;69(2): ) 2010 McDonald criteria 13

14 /6c/Monthly_multiple_sclerosis_anim_cropped_no_t ext.gif Blood studies CVD, Vasculitis and other rheumatologic conditions Infections (Lyme disease, syphilis) Endocrine abnormalities (thyroid disease) Vitamin B 12 deficiency Sarcoidosis Wilson disease (Copper, Ceruloplasmin) NMO (Aquaporin-4 Ab) 14

15 MRI (W and W/O Contrast) Dawson's fingers" Evoked Potentials Visual evoked potentials (VEPs) Somatosensory evoked potentials (SSEPs) Brainstem auditory evoked potentials (BAEPs) 15

16 Lumbar Puncture OCB OCBs are found in 90-95% of patients with MS Ig G Index Intrathecal IgG production is found in 70-90% of patients Treatment Immunosuppression Acute phase: Steroid (Methylprednisolone) Plasmapheresis (2011 AAN guideline: probably effective as second-line treatment for relapsing MS exacerbations that do not respond to steroids. (Cortese I, Chaudhry V, So YT, Cantor F, Cornblath DR, Rae-Grant A. Evidence-based guideline update: Plasmapheresis in neurologic disorders: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. Jan ;76(3): ) Chronic phase: Immunomodulatory therapy for RRMS Immunomodulatory therapy for Progressive MS Immunomodulatory therapy for Aggressive MS Plasmapheresis in neurologic disorders: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. Jan ;76(3): ) 16

17 Immunomodulatory therapy for RRMS Interferon beta-1a (Avonex, Rebif) (Sanford M, Lyseng-Williamson KA. Subcutaneous recombinant interferon-ß-1a (Rebif ): a review of its use in the treatment of relapsing multiple sclerosis. Drugs. Oct ;71(14): ) IM (Avonex) SC (Rebif) Interferon beta-1b (Betaseron, Extavia) SC Peginterferon beta-1a (Plegridy) (Calabresi PA, Kieseier BC, Arnold DL, Balcer LJ, Boyko A, Pelletier J, et al. Pegylated interferon ß-1a for relapsing-remitting multiple sclerosis (ADVANCE): a randomised, phase 3, double-blind study. Lancet Neurol. Jul 2014;13(7):657-65) SC Glatiramer acetate (Copaxone) SC 17