Multiple sclerosis: an expert’s take

Multiple sclerosis, a neurological condition in which the immune system strips off the protective covering of one’s nerves in the brain and spinal cord, is more common than you might think.

Celebrities Selma Blair and Christina Applegate have revealed that they have MS. And, according to Carolina expert Dr. Irena Dujmovic Basuroski, it is believed that about one million Americans live with the disease.

Dr. Irena Dujmovic Basuroski

Dujmovic Basuroski is a clinical associate professor of neurology at the UNC School of Medicine and chief of the multiple sclerosis and neuroimmunology division. The Well asked her to explain the condition and how it affects people — possibly including someone you know.

What is multiple sclerosis? 

Multiple sclerosis is a chronic, inflammatory, immune-mediated and “demyelinating” condition that affects brain and spinal cord. Demyelinating means the myelin sheath, which covers and protects the nerves, gets damaged. It’s also considered a neurodegenerative condition because there is a lot of nerve cell loss that occurs over time in MS.  

The disease can be mild in some people, even so mild that they don’t know they have it. In others, it can be severe and progressive.  

The way MS affects people’s functionality depends on where the lesions are — they can be in the eye nerves, some parts of the brain or at varying levels of the spinal cord. 

What are the symptoms? 

The disease can cause vision problems, tingling, numbness, pain, speech problems, swallowing problems, weakness, balance issues, tremor, walking difficulty, bladder control problems, bowel control problems, sexual dysfunction, cognitive dysfunction (usually slow cognitive processing speed, focusing issues, short-term memory problems), depression and mood changes.  

Christina Applegate receives star on Hollywood Walk of Fame on Nov. 14, 2022. (Shutterstock)

One of the frequent symptoms is fatigue — walking fatigability, overall general fatigue or cognitive fatigue. For example, people with cognitive fatigue cannot watch a whole movie because they cannot track what is going on, so they need to take a break to recharge before they can continue. 

Sometimes MS causes seizures. Migraines are more often diagnosed in people with MS than in the general population. 

However, not every patient has all those symptoms. There are some people with very mild MS who only have occasional tingling in their hands or legs, and there are some patients with MS who have many of those symptoms that slowly get worse. 

When does MS typically get diagnosed? 

It typically gets diagnosed between the ages of 20 to 50. However, around 5% of all MS cases are pediatric-onset cases. Children with MS can get it at any age. MS can be diagnosed in old age, although it is atypical. It is believed that late-onset MS is more likely to be progressive. 

How do people get it? 

MS is a multifactorial disease, so there is no one single cause. There is a lot of research going on looking into genetic and environmental factors for MS, but there is no single factor on either side.  

When we speak about genetic factors for MS, multiple genetic variants were identified and most of them are responsible for controlling how the immune system works.  

Low vitamin D and the lack of sunlight exposure are risk factors. Some viral infections — such as Epstein–Barr virus infection that causes infectious mononucleosis — and various other infections have been linked to multiple sclerosis. Smoking and childhood obesity are risk factors for MS. Early-life environmental factors play a role in susceptibility to develop MS, but several studies suggest that environmental factors might also act later in life. 

Has the rate of diagnosis changed at all in recent years? 

There is an increase in the incidence of multiple sclerosis now when we compare it to the past. It is on one side due to increased awareness of the disease. Neurologists and other providers think more about it when a patient comes with even a mild neurological complaint.  

On the other hand, we now have more availability for MRI studies than we had in the past, so we are able to discover the disease in a much earlier stage. In 2017, we got the latest update of the international diagnostic criteria for multiple sclerosis, and those criteria enabled us to diagnose a definite MS in the early stage of the disease.   

However, what we have also seen is a concern for misdiagnosis. There was a study in two academic centers in California where they looked at the patients that had been referred to their centers under the already-established diagnosis of MS. They reviewed each case and found that, on average, nearly every fifth patient was misdiagnosed (18%). If misdiagnosed, a person gets treatment that they don’t need, including some therapies with potentially serious side effects, and they are not receiving treatment for the condition that they actually have. 

What should people know about MS that maybe they don’t? 

Some MS patients are getting immunosuppressive therapies that weaken the immune system. This is what we expect from the drug, because in MS, one part of the immune system is overreacting, and we need to put it down so that it’s more balanced. 

But some patients have a misconception that MS is a condition where the immune system is weakened even if they have not started with any immunosuppressive treatment yet, and they take supplements to boost it. This is where things might potentially get worse. We don’t know how much those herbal supplements can really be immunostimulating. If they are, can they trigger MS activity? We discuss this issue with our patients to make sure we’re not missing something because sometimes patients don’t report those things.  

It is also very important to explain to patients that so-called disease-modifying therapies we use work in the long term. They are an investment in the future. Those are not treatments that are supposed to improve their current symptoms; for that purpose we have other treatment options. Some patients start on the disease-modifying therapy and don’t see any improvement, so they stop the drug. This lack of adherence to the treatment recommendation is often coming from the lack of education about the treatment goals.   

Some patients in the early phases of MS are reluctant to start treatment because they’re doing well. They ask, “Why should I be on treatment since I’m doing so well?” We need to explain that by starting the disease-modifying therapies early we’re actually investing in their future functionality, since the long-term MS prognosis is much better if the disease-modifying treatment is started early. 

We’re also trying our best to explain to patients that vaccines are not contraindicated in people with multiple sclerosis. If the immune system is weakened because of being on immunosuppressive therapy, people living with multiple sclerosis may have more risk to get infections, so those people need vaccines even more. Therefore, patient education is extremely important in multiple sclerosis care.