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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2745_Библиотеки_им_академика_М_И_Перельмана
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Positive Western blot: considered evidence of tick
encounter, patient positive for Lyme disease
61
CSF Analysis
Patients with the disseminating Lyme disease can develop
neurologic manifestations, or neuroborreliosis, of the disease,
such as meningitis, facial nerve palsy, radiculoneuritis, and focal
encephalitis. Lumbar puncture to analyze CSF is useful in
determining a definitive diagnosis of Lyme disease as the source
of those symptoms and what antibiotic would be the most useful
for treatment. For example, oral amoxicillin is appropriate for
treating arthritic manifestations of Lyme disease, but not
neurologic; however, oral doxycycline could treat both. 61 It
should be noted that CSF analysis for patients with
neuroborreliosis and MS would yield OCBs, but the OCB
antibodies found in the patient with suspected neuroborreliosis
binds specifically to a protein from Borrelia, and the patient can
be differentiated from a patient with MS.
23,64
Imaging
Persisting Lyme disease often affects the central nervous system
with demyelinating lesions, which can be misdiagnosed as MS.
65
MRI may reveal white matter hyperintensities suggestive of
inflammation or areas of demyelination. However, antibiotic
treatment results in a decrease or disappearance of these
hyperintensities. Clinical presentation and blood serology should
rule out these regions of hyperintensities in patients with
neuroborreliosis.
61,62
Gout
Pain from gout is often confused with that of MS, when another
inflammatory source is gouty arthropathy presenting in a patient
with MS. Gout is characterized by acute, intermittent episodes of
synovitis caused by the accumulation of monosodium urate
crystals in joint fluids, cartilage, bones, tendons, bursae, or other
sites.
66,67
Pain from gout is often described as a sharp or burning
sensation and commonly presents with considerable erythema,
swelling, and increased temperature. It most commonly affects
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the great toe joint, although it can manifest in any synovial joint.
Neuropathic, ongoing extremity pain can overlap with symptoms
of gout manifesting in the great toe, ankle, or knee joints. Acute
swelling, erythema, or increased temperature, particularly when
manifesting in intermittent episodes, enforces gout as a probable
differential diagnosis. Additionally, gout interacts with
nociceptive pain secondary to musculoskeletal stress in MS and
will likely lead to compensational pain as a result of the patient
shifting gait to avoid putting weight on the affected joint. The
characteristic findings of gout noted earlier can be used to
differentiate a manifestation of gout from another source of
synovitis in patients with MS.
67
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C H A P T E R 1 3
Pulmonary Complications in
Multiple Sclerosis
Priyank Trivedi Anthony J. Smith Joseph T. Cooke
Introduction
Pulmonary complications are a significant cause of morbidity
and mortality in patients with multiple sclerosis (MS).
Symptoms are insidious, and respiratory dysfunction may
present as late as 9 years after the onset of neurologic
symptoms. 1 The pattern, severity, and morbidity of respiratory
failure is related to the size and location of the demyelinating
plaques within the central nervous system. The respiratory
dysfunction is related to the degree of neurologic involvement
and related respiratory muscle weakness. This is manifested as
loss of ventilation control, sleep apnea, difficulty swallowing,
and an ineffective cough. Current and future treatments for MS
may also result in a decreased immune response to infection.
The respiratory failure treatment is often supportive, with both
invasive and noninvasive mechanical ventilation.
Pulmonary Function Testing
Pulmonary function tests may not be the most sensitive marker
of respiratory muscle dysfunction in MS. 2 Common
measurements used to measure respiratory function in patients
with MS include vital capacity (VC), maximal inspiratory
pressure (MIP), maximal expiratory pressure (MEP), and
maximal voluntary ventilation (MVV).
Reduction of the VC suggests significant diaphragmatic
weakness. Patients often exhibit correlative signs such as
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paradoxical abdominal breathing. The MIP, MEP, and MVV,
in contrast, are more sensitive indicators of respiratory muscle
weakness. 3 Similar to other neuromuscular diseases, the
decline in MIPmax and MEPmax precede changes in lung
volumes. Patients with moderately severe MS on average
exhibit a 40% decline in MIP and a 60% decline in MEP.
8
MVV measures the respiratory muscle endurance. This
decreases in parallel to the decrease in MEP.
4
Studies have demonstrated a larger decrease in expiratory
muscle strength than in inspiratory muscle strength. Expiratory
muscle weakness can occur without inspiratory muscle
weakness in patients with mild disease. 5 This pattern can be
explained by the progression of paresis in patients with MS. In
MS, muscular impairment generally progresses from lower to
upper extremities. The abdominal muscles become impaired
earlier than the muscles of the diaphragm and intercostal
muscles. This results in impaired expiration before inspiration.
6
This can be clinically manifested as an ineffective cough and
an inability to clear secretions.
Respiratory muscle weakness occurs both in patients who are
ambulatory and wheelchair bound. However, patients who are
ambulatory with minimal upper extremity involvement have a
much smaller decline in MEP, VC, and MVV and essentially
no decline in MIP when compared with patients who are
wheelchair bound with significant upper extremity impairment
4
(Figure 13.1). Patients with a mild degree of neurologic
impairment rarely show any abnormalities in pulmonary
function testing with normal (VC), forced expiratory volume
in 1 s (FEV1), total lung capacity (TLC), and residual volume
(RV). In contrast, patients with more advanced disease may
show lung volume loss with a decreased VC and a preserved
FEV1/FVC ratio. This pattern suggests restrictive lung
disease; however, the TLC tends to be preserved in MS
5
(Figure 13.2). This is attributable to submaximal inspiratory
and expiratory efforts that are expected in patients with whole
body muscle weakness, which results in an increase of the
residual volume (RV). The rise in the RV correlates with the
decline in the MEP.
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FIGURE 13.1 Measures of respiratory muscle function by
category of neurologic disability expressed as percent
predicted.
Reproduced with permission from Smeltzer SC, Skurnick JH,
Troiano R. Respiratory function in multiple sclerosis: utility of
clinical assessment of respiratory muscle function. Chest.
1992;101:479-484.
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FIGURE 13.2 Pulmonary function test results by category of
neurologic disability expressed as percent predicted.
Reproduced with permission from Smeltzer SC, Skurnick JH,
Troiano R. Respiratory function in multiple sclerosis: utility of
clinical assessment of respiratory muscle function. Chest.
1992;101:479-484.
Although MIPs and MEPs provide for a more useful tool than
usual pulmonary function tests, they can be difficult to
administer in patients with facial and bulbar muscle weakness.
7
Clinical indices may be the best predictor of expiratory
muscle weakness. 5 Activities such as talking, coughing, and
upper extremity strength serve as reliable markers of muscle
strength. Talking requires complex coordination of upper and
lower respiratory muscles, and coughing requires muscle
contraction against a closed glottis. Smeltzer et al developed a
pulmonary index score that appeared to be the best predictor
of expiratory muscle weakness. The score comprised four
parameters: patient’s report of his or her ability to handle
secretions/mucus, patient’s report of a weakened cough,
examiner’s evaluation of a patient’s cough when asked to
voluntarily cough as forcefully as possible, and the patient’s
ability to count on a single exhalation. Using stepwise
regression analysis it was concluded that the index score,
upper extremity weakness, and MVV accounted for 60% of
the variance in maximal expiratory muscle strength.
5
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