MUDr. Eva Krasulová, PhD.: When your own cells start attacking your body

Article

12. 10. 2022

Tingling, impaired balance, poor mobility. These are only a few of the manifestations of multiple sclerosis, a potentially disabling disease that doesn’t only affect young women. How is MS treated today, who is at risk and what the neurological examination entails, explains Eva Krasulová, PhD, a neurologist at the Canadian Medical Clinic.

Which neurological diseases are among the most common in the Czech Republic?

From purely neurological diseases, headaches rank first. Back pain follows. But here, more often than a neurological disease per se, it is a multidisciplinary problem where a general practitioner, a rehabilitation doctor or a traumatologist/orthopaedic surgeon has a say. Of the acute conditions, the most common are strokes which - with the exception of the infectious disease covid-19 - are the second most common cause of death in this country.

In the context of an ageing population, the number of patients with dementia is on a rise. Poor lifestyle habits and other factors are leading to an increased incidence of autoimmune diseases such as multiple sclerosis.

How do you screen for such diseases?

First, there is a basic examination by a neurologist: taking a medical history through an interview with the patient and an objective neurological examination. This includes an examination of all the basic systems of the nervous system, from eye movement to limb mobility, the equipment of reflexes using a special neurological hammer, and finally an observation of standing and walking functionality. The initial examination concludes with a summary of symptoms, a suspicion of a possible diagnosis, and a proposal for further examination and treatment.

What can the initial examination reveal?

An objective neurological examination in our outpatient offices, we are able to distinguish between significant disorders of the central nervous system, i.e. the brain and spinal cord, the peripheral nervous system, i.e. the nerve roots protruding from the spinal cord and the nerves in the limbs or muscles. Accordingly, we send the patient for more specific examinations such as an MRI, CT, cerebrospinal fluid sampling, EMG, EEG and others. However, in the case of a headache or a history of epileptic seizures, it is necessary to undergo brain imaging even for patients with a normal neurological examination.

In your own work, you focus on multiple sclerosis. What does a typical patient look like?

In the waiting room of a specialized centre for multiple sclerosis, MS, you will see mainly young, working people between the ages of 20 and 40, who wouldn’t look like a person that you would expect to have a neurological disease: this is thanks to an early diagnosis and adequate treatment with modern medication.. Of course, you will also come across patients with disabilities, but these are usually patients diagnosed late or diagnosed at a time when modern drugs were not available. With all of today's treatment options, only about 5-10% of patients are at risk of rapidly developing a disability.

Do they know what causes the disease?

Multiple sclerosis is an autoimmune disease in which there is a faulty response immune system. Instead of protecting the patient from viruses, bacteria or cancer cells, it attacks the body's own structure. In the case of MS, it attacks the structures of the brain and spinal cord. We do not know the exact reasons that lead to disorders of autoimmunity in a particular patient, but it is always a combination of risks. A clear risk factor is a history of infection with the EBV virus-infectious mononucleosis. But other risks, which fortunately can be easily eliminated, are vitamin D deficiency and smoking.

What does MS look like?

Typical symptoms are persistent tingling of any part of the body lasting more than 24 hours, impaired sensation in body parts, impaired mobility, impaired balance, urinary disorders without a urological cause, optic neuritis or double vision.

How is MS diagnosed?

In addition to an objective clinical examination, MS is diagnosed using an MRI of the brain and spinal cord and an examination of the cerebrospinal fluid by lumbar puncture. The much-feared lumbar puncture is no longer a burden for the patient thanks to the modern needle. Hospitalization is also not necessary.

What are the treatment options and what does care for the patient in the long term look like?

We currently have a wide range of effective drugs available. For acute exacerbations - ataxia - we use proven corticosteroids. Long-term preventive treatment aims to prevent further attacks and permanent increases in disability. It includes biological treatments that interfere cleverly with the immune system. It is more difficult to treat slowly progressing MS (primary and secondary progression) compared to MS with acute flare-ups, but we do have biological treatments available for these patients as well. Long-term care requires regular follow-ups in a specialised centre, MRI scans, monitoring of disease progression with possible treatment changes and monitoring for possible side effects of treatment. This includes comprehensive care of the patient in cooperation with other specialists.

Is there any vision of a complete cure in the future?

A complete cure is not yet on the horizon, because it would have to involve stopping the faulty immune system's fight against the brain and spinal cord and the simultaneous repair of the damaged areas of the central nervous system. One possible hope from an immune system perspective could be to influence the gut microbiome, as immune responses in the gut have been shown to be extremely important in autoimmunity. Drugs are also being tested to repair nerve sheaths in the brain and spinal cord. Unfortunately, we cannot yet replace the nerve fibres themselves, the loss of which is responsible for the patient's disability.

Does this diagnosis allow the patient to lead a full life - to play sports, and to start a family?

The main reason for a drive for an early and rapid diagnosis is to ensure the start of effective treatment in order for the patient to be able to lead as normal of a life as possible. In the beginning, the young patient has to overcome the certain "shock" of the diagnosis, absorb the first intensive contact with the health care system, to cope with the knowledge of a chronic and not yet curable disease, for which we are not able to predict the exact course. The whole period of "coming to terms" with MS lasts at least a year. Patients are then supported as much as possible in maintaining their ability to work, as this is fully preserved in most cases. Even starting a family is not a problem today; for women, we only discuss the timing of pregnancy in advance until the disease is optimally stabilized. And we strongly recommend physical activity.

Outside of your medical practice, you lead a lot of lectures. What do you usually talk about?

My main topic of discussion is of course the subject of multiple sclerosis. At the same time, I focus on a special group of diseases at the border of several medical disciplines, which can be collectively referred to as neuroimmunological diseases. These include, for example, autoimmune vasculitis, neurological complications of rheumatological diseases, rarer inflammatory diseases of the brain and spinal cord, and others. Although there are far fewer patients with these diseases than those with MS, in practice they have difficulty finding a specialist to deal with their neuroimmunological disease.

You have spent your entire professional life caring for patients with chronic and often incurable diseases. Isn't that a sad profession?

Medicine also includes very sad times when we fail - whether in the sense of advancing disability or a fatal disease for which there is no solution anywhere in the world. Nevertheless, I wouldn't change my profession because I am convinced that in our field, greater or lesser successes prevail, where the patient can be helped completely, partially or at least for a certain period of time. 

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