(bright music) (bright music continues) - It's an unpredictable chronic autoimmune disease and neurological disorder that millions of Americans live with.

Tonight, everything you need to know about MS.

(lively music) (lively music continues) (lively music continues) Good evening and thanks for joining us for WTVP's "Docs on Call".

I'm Mark Welp.

MS or multiple sclerosis affects people differently and is not easy to diagnose.

Dr.

Jacob Tony is a neurologist with Carle Health and he's here to tell us what doctors do know about this sometimes mysterious condition.

Doctor, thanks for coming in.

- Thank you very much.

My pleasure.

- So let's talk about multiple sclerosis.

What is it?

- Multiple sclerosis is defined as a disease which is autoimmune, demyelinating and inflammatory.

So it's autoimmune because our own immunity attacks the proteins in the brain and thereby it creates more inflammation and the inflammation will lead to degeneration of the nerve cells.

So when there is a combination of inflammation, demyelination, demyelination actually means our nerve cells are covered.

In fact, they are insulated by a protein called myelin.

So that myelin is sort of chipped away.

So because the myelin is chipped away, it is called demyelination.

So that demyelination leads to inflammation and then eventually there is degeneration of the cells.

So that degeneration of the cells will now produce sort of like a scar called a plaque.

So these plaques can affect multiple parts of the brain.

And because it can affect multiple parts of the brain, it can produce multiple symptoms and multitude of problems.

And over a period of time, these plaques will accumulate in the brain eventually producing disability.

So that is the concern about multiple sclerosis because it's an autoimmune disease with chronic inflammation and a tendency for remissions and exacerbations.

So they keep on getting these attacks unless we treat that with some disease modifying agents.

- [Mark] Do we know what causes it?

- Well, there are three, I would say there are three domains.

One is environmental factors.

The other one is there is some genetic factors and the third we call epigenetics.

Now when we talk about the environmental factors, one of the important factor is Epstein-Barr virus, the same virus that produce infectious mononucleosis.

There are other viruses incriminated, but mainly Epstein-Barr virus.

Now what happens is when a person has Epstein-Barrus infection, the body will react to that because it's a foreign body by producing our immune system to come to full force.

But then there's a catch there.

Now, one of the protein in the Epstein-Barr virus resembles the protein in the myelin.

In fact, there is a protein called myelin-basic protein.

So our brain will here become something like an innocent bystander.

So in the act of attacking the Epstein-Barr virus, mistakenly our immune system will act against our own myelin, thinking that this is the protein which looks like Epstein-Barr virus.

So it's called molecular mimicry.

In other words, the molecules sort of mimic each other.

And therefore what happens?

The immunity that should be attacking the Epstein-Barr virus, that same immunity will now attack the myelin and then produce demyelination.

So that's a big factor.

They have also found for some reason it is more common in the northern latitude.

So we see multiple sclerosis mostly in North America as well as in Europe.

I'm originally from India and when I was in India in the medical school, I have seen one, only one multiple sclerosis.

It's so rare.

And I remember that patient was actually an Irish nun.

She's not even a person from India.

So there is something about the latitude and people think it may be related to the Epstein-Barr virus, may be related to the sunlight exposure, and also vitamin D. There are a lot of studies which says that vitamin D deficiency has a positive correlation with multiple sclerosis.

In fact, I told you about genetics.

In genetics and epigenetics, there are some cells called HLA, human leukocyte antigen.

This HLA system and its relation to vitamin D has also been incriminated.

So I told you about genetics.

There is a specific genetic program called HLA, and in that HLA, there is an HLA-DR15.

And people with that HLA-DR15 has some genetic tendency to develop multiple sclerosis.

So that might be another reason.

Sometimes we see clustering of multiple sclerosis in families, and that clustering can happen because of this HLA.

That is a second thing.

And then in addition to genetics, epigenetics.

So epigenetics is not genetics by itself, but the DNA can undergo some chemical process called methylation, histone.

So because of those changes, you can get multiple.

So some people, because of that, also are more prone to get multiple sclerosis.

Having said that, there are also studies which says that people who smoke, smokers, smoking or tobacco, it can actually break the blood-brain barrier.

In other words, the brain is insulated to some extent from immune attack because of what we call a blood-brain barrier.

But if you keep on smoking, the tobacco and the nicotine can break that blood-brain barrier.

So what does that mean?

That means the immune system which is in the blood can easily cross the blood-brain barrier and easily attack the brain.

So smokers are more prone to get multiple sclerosis than non-smokers.

There are some associations with obesity, as I told you, some association with light, sunlight exposure and the lack of that vitamin D deficiency.

So these are all the theories as far as environmental factors are concerned about multiple sclerosis.

But the most important thing of all is Epstein-Barr virus, you know, infections related to that and the molecular mimicry.

- And I read a statistic that about worldwide, about 70% of cases are women.

- [Dr.

Jacob] Yes, that's correct, yes.

- Do we have any idea why that is?

- We don't know exactly, but that is a ratio.

They say about three is to one.

Women are more prone, for whatever reason, to get multiple sclerosis.

And that is a big concern because when you see a patient with multiple sclerosis, it's more often than not a lady in the reproductive age group and usually in the 30s.

So the median age is 30 and a typical person is a lady.

I would say ladies outnumber men, three is to one.

So the greatest concern is how do you treat them because of childbearing age group, you know, pregnancy, fertility, effect on pregnancy, pregnancy's effect on multiple sclerosis.

And you know, should we continue the treatment during pregnancy because of potential effect on the baby?

So these are consideration particularly in women.

Other factors may be contributing, for example, vitamin D deficiency.

So one of the recommendation is that women with multiple sclerosis planning for pregnancy should always take vitamin D supplements, very important and should avoid smoking.

- I have a friend who, this was 25 years ago, she got diagnosed with MS and she didn't have kids and her doctor at the time told her, "If you want to have kids, you want to do it sooner rather than later."

- Yeah.

I mean, generally what they do is, the general recommendation is once multiple sclerosis is diagnosed, you wait for about two years before planning pregnancy.

So the idea is to sort of stabilize the disease.

The older time, historically, they said, "Well, you know, you don't have to take the multiple sclerosis medicines during pregnancy because pregnancy has a protective effect on multiple sclerosis."

In other words, during pregnancy, the attacks of multiple sclerosis for some reason are less than in an unpregnant woman.

But the thinking has changed.

Now we have experience for about three decades.

As you know, the first multiple sclerosis medicine called beta interferons came in 1993.

So we are talking about millennias of multiple sclerosis, I'm sure.

And we had no advancement at all in the treatment of multiple sclerosis all these years.

And people used to go into despair with the diagnosis of multiple sclerosis.

But in 1993, '94, the first interferons were marketed.

And I remember I was in England at that time and you know, it was a big news.

You know, the first interferons are coming.

And I remember seeing patients with multiple sclerosis there and it was pretty sad.

And we were very, very careful in giving that diagnosis because of the implications.

You know, people can lose eyesight, they could be wheelchair dependent, can lose control of the bladder.

So it is a great blessing in the last 30 years.

The first one was interferon, but as we speak in 2026, we have 20 multiple sclerosis medications and still counting.

There is one which is in the pipeline called the Bruton kinase inhibitor, which is in pipeline two.

So 20 and counting.

And there is no reason why a person diagnosed with multiple sclerosis should deny treatment to themselves because it is a miracle.

- So there is no cure for MS, but are these medicines, are they helping people have a better quality of life?

Is that what they're doing?

- Yeah.

I mean, I would say there are two ways of looking at it.

One is, once you have a multiple sclerosis, once you're diagnosed multiple sclerosis, the most common form of multiple sclerosis is called relapsing or remitting type.

That means they get periodic attacks, you know, relapses.

And the idea of treatment is to prevent these future relapses.

So if you keep on getting relapses and you keep on getting these plaques, the plaque burden in the brain will increase.

And as soon as the plaque burden of the brain increases, you get multiple problems in multiple domains of the brain and that will lead to progressive disability.

So these medicines are therefore called disease modifying treatment.

It modifies the disease, DMT.

So what do the disease modifying treatment?

Because it is playing with our immune system, either immunomodulators or immunosuppressants.

By playing with our immune system, it prevents future attack.

And if you prevent future attacks, you prevent future plaque formation and therefore eventually will also reduce the incidence of disability.

Yes.

So it definitely increases the quality of life.

Yes.

- Let's go back a little bit and talk about some of the symptoms.

You know, when people start to have symptoms and they go to their doctor and they say, "Okay, it's not this and it's not this."

With MS, I mean, there is no one specific test, is there to diagnose it?

- There are a few tests, basically MRI and spinal tap, and there are some visual tests too.

Yeah, looking at the eyes.

But basically the symptoms, when you talk about the symptoms, it's very important to have that understanding of the symptoms.

We'll start with the eyes.

One of the common symptoms is something to do with the eye.

Either they can lose eyesight, they may complain of double vision, they may have problems with color vision, or very commonly, they say that when they are moving their eyes, they get pain.

So when they get pain, when they move their eyes, if they are seeing, having problems with color vision, double vision, or sometimes the eyes keep moving around, that's called, we call nystagmus.

So when you have any of those eye symptoms, don't ignore that.

Very important.

If you get an eye symptom like that, suddenly losing eyesight, please don't wait.

Just go to the ER.

Why do I say ER?

The reason is that high dose intravenous steroids, studies have shown that it will help with that.

That is the first step, high dose intravenous steroids.

They have compared intravenous steroids with oral steroid tablets, but intravenous steroids is any day better than that based on the studies.

And because you don't want to lose your eyesight, people can lose the eyesight.

So that is one thing.

The second thing is that occasionally they can get vertigo.

You know, we see people having the spinning sensation.

So inexplicable vertigo, particularly in young people, you have to be careful about that.

The third thing is what we call trigeminal neuralgia.

I'm sure that you have heard about that, right?

I mean, people getting this sort of shooting, lancinating pain on one side of the face because the face is supplied by a nerve that come from the brain called trigeminal nerve.

Trigeminal because there are three divisions to that.

And if a young person, particularly a lady, all of a sudden develop trigeminal neuralgia, they may have MS.

So do not ignore if you get shooting, lancinating pain on one side of the face.

That's another important thing.

I've seen few patients who come with what we call Lhermitte's sign.

So what happens is that whenever they bend their neck, when they flex their neck, they get a shooting electric pain going down.

That is called Lhermitte's sign.

It can happen in people with multiple sclerosis.

- [Mark] Going down their spine?

- Yeah.

No.

- [Mark] Or the front?

- The whole body.

Yeah.

- [Mark] Oh, the whole body.

- Yeah, Lhermitte's sign.

So in fact, I have few ladies who presented with that and their main symptom was that Lhermitte's sign.

So we call it Lhermitte's sign.

That's another one.

And also some of these patients with MS or underlying MS may have transcend weakness, again, when they bend the neck.

So that's an important thing.

And I'm sure that a lot of people know about MS hug.

I get this feeling that there is a stiffness which comes and goes usually in the chest or torso.

It is actually because of spasticity.

Spasticity means the muscles are very stiff because of MS.

And when spasticity happens, it can be in two ways.

One is what we call a continuous spasticity.

The other one is a phasic or dynamic spasticity where it comes and goes.

And this MS hug is something like a dynamic spasticity where you get this feeling of spasticity coming and going.

That's called MS hug.

Very, very important to remember one more thing.

That is, if you get a band of anesthesia, in other words, a band over the chest or the torso where you don't feel the sensation, or if you do get some burning sensation, any strange sensation or lack of sensation in the form of a band in the chest of torso, please do not ignore.

The reason I'm telling you, I have seen patients.

In fact, I know a person, a lady who had this band of anesthesia across her chest, and she was applying some little cream or something over there.

And I knew her and she called me and I said, "No, I mean, you have been doing this for weeks.

Please don't do that.

Go and get an MRI straight."

And she got an MRI, spinal tap.

This was about 20 years ago, and it shows she had MS.

And that time we had only three MS medicines.

Today she's doing very well.

She has climbed on the corporate ladder.

She has children.

She's doing very well.

What if in an alternate universe she ignored it, she could have been disabled.

That's why I want to say again, I've seen few patients like that.

Again and again, I want to say, "If you do get a band of anesthesia which lasts more than 24 hours in the chest or torso, please don't.

It has to come from the spine."

- Now when you say band, do you mean a specific like area?

- It can be any area because you see, I say band because spinal cord will supply sensation to the chest as well as the abdomen, right?

There are multiple nerves that come from the spinal cord.

So it depends upon which nerve and which area.

So there are multiple nerves.

Okay?

So if it is here, we say T5, thoracic five.

If it is farther down, we say T10.

So depending on whether it's thoracic five, thoracic 10, wherever, in the chest or torso you see, or rather how this strange burning sensation or a band of anesthesia.

And if it lasts more than 24 hours, please seek help because that is suggesting that something is going on with the spinal cord and if it is ignored, person could be paralyzed.

That's another thing.

Bladder symptoms.

A person who never had bladder symptoms now start having frequency of urination, you know, the urgency of urination, that's important.

So fatigue, extreme fatigue for no reason at all.

A person was doing well and all of a sudden they are getting fatigue.

So these are some of the common symptoms in addition to weakness and unsteady gait, very common.

Ataxia gait, we say they lose balance.

So if you see any of these symptoms, don't wait, get immediate help.

- With those symptoms, you know, you mentioned if you start having eye problems, go straight to the ER.

- Yeah.

- But the eye problems, some of the tingling, that could potentially be something besides MS.

So how do you know if I should go to my family physician first and then be referred to someone?

Or should I go to a neurologist first?

How do you work that?

- I mean, eyesight, I would say go to the ER because you don't want to, you know.

The other one, you can always talk to your primary care physician.

But if you see, for example, weakness or unsteady gait all of a sudden, you don't want to wait.

That means the motor system is affected, but the other one is mostly sensation, tingling in the hands and legs.

But the motor system is affected, which means they have weakness or unsteady gait.

That is serious because if you ignore that, you know, it can get even worse, right?

It can lead to disability.

So contact your primary care doctor, go to your neurologist.

But if you think that things are getting weakness, that's the purpose of an ER.

- I think everybody understands what an MRI is and how it works, but as far as the spinal tap, tell us a little bit more about how that procedure's done and how invasive it is or isn't and what people can expect.

- Yeah.

I will first say about the MRI because I cannot ignore the MRI.

MRI is the single most important paraclinical diagnostic tool to diagnose MRI and not CT scan.

MRI is very, very, very important.

Now, there is a way in which we diagnose MS and the criteria keeps evolving as we get more and more information based on data and research.

So I just called the McDonald's criteria There was a criteria in 2017, and now we have a criteria in 2024.

So it is the latest criteria we use now in 2026 is called the McDonald's 2024 criteria.

So according to this criteria, other than all the clinical findings, you had to get an MRI scan of the brain, very important.

You had to also get an MRI scan of the orbit to look at the optic nerve if they have eye signs and MRI of the spine.

So these are what MRIs are recommended according to the McDonald criteria.

So in the MRI of the brain, what are we looking for?

We are looking for lesions which look either round or over-shaped, multiple lesions in various areas, and there are certain areas of the brain that specifically are attacked by multiple sclerosis.

So neurologists as well as neuroradiologists know that.

We call it juxtacortical.

So we know that the brain has a cortex and inside the gray matter and the white matter.

So if you see the lesions are very near to the cortex, we call it juxta cortical, that could be MS.

If it is very near to what we call the ventricles, and the ventricles are actually that fluid filled chamber in the brain, you know, it looks like a butterfly.

When you look at the CT scan or MRI, what you see as a butterfly inside, that is actually a fluid filled chamber.

That chamber is called a ventricle.

So when you see plaques or lesions just on the side of those, we call periventricular lesions, they are also very indicative of multiple sclerosis.

Similarly, if there are brainstem, back part, brainstem or cerebellum, what we call infratentorial or in the spinal cord.

So when we have this pattern along with what we call optic neuritis, these are the things that we look for MS.

And then there's a criteria where we look for.

Basically the criteria is two things we have to satisfy, dissemination in time because of relapsing, remitting nature and dissemination in space.

So space is that you see the lesions in multiple parts, like what I said, juxtacortical, periventricular, infratentorial, brainstem, spinal cord, optic nerve.

And when we say dissemination time, either if the patient had two attacks, clinically, patient says that, "Yeah, I had problems with the eye and now I'm getting a band on my chest."

So we know that happened, the eye was attacked a few months ago and now we are getting a band of chest.

That's dissemination in time.

But sometimes there is something called clinically isolated syndrome.

Patient comes first time, so we do not know what happened in the past and we cannot wait for the future.

So we sometimes diagnose MS from clinically isolated syndrome.

There you look for dissemination in time by looking at the lesions.

If the plaque is not enhancing, that means we inject a dye and the dye shows there is an enhancement of the plaque, the plaque is lighting up, that means it's an angry lesion.

That means it is new.

But if you are seeing lesions which are not lighting up, that means they are old lesions.

So now we know, oh, there are old lesions that are angry, new lesions which are lighting up.

What does that mean?

That means there's a dissemination in time, right?

So when you have both dissemination in time and dissemination in space, you diagnose MRI.

I mean, based on the MRI, you can.

Spinal tap.

Coming to spinal tap, I mean, I used to do a lot of spinal tap, you know, bedside.

Nowadays, we send to the interventional radiology because it's easy.

They can project an x-ray there.

They can see where they are going.

They go between the vertebrae, give some local anesthesia, and it's actually not a big procedure.

It's okay because you know, we always give local anesthesia so that we are numbing the skin.

The only thing is after spinal anesthesia, I mean, not spinal anesthesia, spinal tap, they should not sort of exert too much or walk around, lie down, drink plenty of water because sometimes there could be a spinal leak.

Spinal fluid is very important because it will be looking at two things which suggest there is some immune reaction going on in the spinal fluid.

We call it intrathecal immune changes.

One is called oligoclonal bands.

So these bands of proteins, if it is two or more, that is indicative of MS.

In that clinical situation with the MRI findings, or the McDonald's criteria in 2024 has also added something called Kappa-free light chains.

The Kappa-free light chains are also light chains associated with the immunoglobulins, you know, fragmented immunoglobulins.

So if you see that in the spinal fluid, then you meet the criteria for making diagnosis of multiple sclerosis.

- One thing people may be wondering with this, and maybe it's changed over the years, but is there a life expectancy that's different from people who don't have MS?

- I don't think that's a problem right now because it was in the past.

With the disease modifying treatment, they can enjoy all the privileges of a person who does not have MS.

They can bear children, they can breastfeed children, they can have, as I told you, the lady before, you know, she has climbed really well in the corporate ladder.

I mean, no, it doesn't hold you back.

But in the past, yes, you're right.

I mean, I do remember.

It was a death sentence at that time.

If you see MS, now, we are very, very reluctant to tell that.

It was so sad.

People are on wheelchairs and they are on indwelling catheter you know, and then cannot see and cannot even sit on a wheelchair because of something called truncal ataxia because they cannot hold their trunk and you know, they are losing balance even sitting on a wheelchair.

So it was pretty bad those years.

So since 1994, the world has changed.

We are living in a new world and it's unfortunate.

I have few patients who doesn't want to take medications despite telling all this.

- [Mark] Really?

- Really.

I cannot understand that.

Then we have 20 medicines, think about the time before you know, 1994, you know, 1990s, 1980s, there was only steroids.

There was no treatment.

Now we are 20 and counting and still if people, I just cannot get that.

- Are they worried that the side effects are gonna be worse than the MS?

- Some people are in denial.

Some people are in denial.

I think it's sad.

I mean, despite.

So the only thing we can do is try to educate.

I mean, that's the purpose of our talk today, right?

I mean, so that we don't want to deny that.

This is a real disease and there is treatment available and they can have a good life, good quality of life.

- And getting it diagnosed quickly is a big key, I'm sure.

- Very, very true.

Very, very true.

I just want to add one more point.

They have shown that, as I told you, the most common form of multiple sclerosis is relapsing remitting type, right?

But there is another type of multiple sclerosis called secondary progressive multiple sclerosis.

That means though it is relapsing, remitting initially, and then it will have a relentless progress, progression of the disease, and they'll go to disability very fast.

They have shown that if relapsing remitting multiple sclerosis is untreated for 25 years, they will invariably go into this progressive multiple sclerosis, secondary progressive, and that is bad.

So anybody who's under.

So there is no explanation for not being treated in the modern world.

- All right.

Well, doctor, unfortunately, we're out of time.

I got a lot more questions.

We may have to do a part two here pretty soon.

But you definitely gave us some good information today and hope people, again, take care of their bodies and listen to their bodies.

- Sure.

Yeah.

- We appreciate it.

Dr.

Jacob Terry is a neurologist with Carle Health.

- Thank you very much.

Appreciate it.

Thank you.

- And thank you for watching.

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You can share it.

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Take care of your family.

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