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C H A P T E R 2 0
Multiple Sclerosis in
Adolescents and Children
Tanuja Chitnis
Introduction
There has been an increasing awareness of the occurrence of
multiple sclerosis (MS) in children and adolescents since
approximately 2004. Whether this is due to a true increase in
incidence or improved diagnostic criteria and dedicated
pediatric MS centers is still unclear. However, it is clear that
children can get MS and that this form of disease requires
specialized treatment and management.
Pediatric MS is defined as MS with an onset younger than age
18 years. There are some variances in the literature, using a
cutoff of age 16 years; however, for practical purposes, most
studies including treatment trials use age 18 years as the
cutoff.
1
There have been reports of children as young as 2.5 to 3 years
old at the time of the first attack of MS; however, the vast
majority of patients are 11 years or older, with a mean age at
onset of 15 years in the US Network of Pediatric MS Centers
at the first symptom. Puberty seems to be an important
transition time for the onset of pediatric MS, 2 with 80% to
85% of children being peripubertal or postpubertal at the time
of the first symptoms in a large US cohort. 3 Approximately
3% to 5% of all MS patients are pediatric at the time of first
symptoms.
4
Reports from many centers around the world indicate that the
pediatric MS occurs in many regions. Higher prevalence rates
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are generally reported from regions more distal to the equator.
The estimated incidence is approximately 0.51 per 100,000
insured persons less than age 18 years 5 in a California study,
and 2009 to 2011 incidence was estimated at 0.64 per 100,000
in an incidence study from Germany.
3,6
A recent report from
Canada found the age-standardized annual incidence of MS in
the pediatric population ranged from 0.99 to 1.24 per 100,000
population, and the age-standardized prevalence ranged from
4.03 to 6.8 per 100,000 population.
7
The diagnosis of pediatric MS rests on clinical and magnetic
resonance imaging (MRI) features, and the updated diagnostic
criteria published in 2013 from the International Pediatric MS
Study Group 8 have been the general standard for diagnosis.
However, these criteria are updated every 4 to 5 years as more
information regarding MRI features and differential diagnosis
becomes available. The diagnostic criteria for pediatric MS are
listed in Table 20.1.
Table 20.1
Summary of Proposed Definitions of Pediatric Acquired Demyelinating
Syndromes (IPMSSG Criteria): Diagnosis of Pediatric MS Must Meet
Criteria for Both Dissemination in Time and Dissemination in Space
Dissemination in Time (DIT) Dissemination in
Space (DIS)
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Dissemination in Time (DIT) Dissemination in
Space (DIS)
One of the following DIT criteria must be met:
Two or more nonencephalopathic (e.g., non-acute
disseminated encephalomyelitis [ADEM]) clinical
CNS events with presumed inflammatory cause
separated by more than 30 d involving more than
one area of the CNS
One nonencephalopathic episode typical of MS
that is associated with MRI findings consistent
with 2010 Revised McDonald criteria for DIS and
in which a follow-up MRI shows at least one new
enhancing or nonenhancing lesion consistent with
DIT MS criteria (irrespective of its timing with
reference to a baseline scan)
One ADEM attack followed by a
nonencephalopathic clinical event, 3 or more
months after symptom onset, that is associated
with new MRI lesions that fulfill 2010 Revised
McDonald DIS criteria (at least one T2 lesion in
two of the following areas: periventricular.
juxtacortical, infratentorial, and spinal cord)
A first, single acute event that does not meet
ADEM criteria and whose MRI findings are
consistent with the 2010 Revised McDonald
criteria for DIS and DIT (simultaneous presence
of asymptomatic gadolinium-enhancing and
nonenhancing lesions at any time). These criteria
apply only to children <12 y old
2010 Revised
McDonald criteria
for DIS; at least one
T2 lesion in two of
the following areas:
Periventricular
Juxtacortical
Infratentorial
Spinal cord
Reprinted with permission from Krupp LB, Tardieu M, Amato MP, et al.
International Pediatric Multiple Sclerosis Study Group criteria for pediatric
multiple sclerosis and immune-mediated central nervous system demyelinating
disorders: revisions to the 2007 definitions. Mult Scler. 2013;19:1261-1267.
Copyright © 2013 SAGE Publications. CNS, central nervous system; MRI,
magnetic resonance imaging.
Typical MRIs from a pediatric patient with MS are shown in
Figure 20.1.
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FIGURE 20.1 (A) Magnetic resonance imaging (MRI) findings
in pediatric multiple sclerosis. (B) MRI cervical-thoracic spine.
(C) MRI orbits.
Differential Diagnosis
The differential diagnosis of pediatric MS is similar to that of
adult MS, with the following caveats. Acute disseminated
encephalomyelitis (ADEM) occurs mainly in children 9 and is
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an important differential diagnosis of pediatric MS. Rarely,
ADEM events are the first event of pediatric MS, and for this
reason, children with ADEM should be followed
longitudinally by a neurologist. Some differentiating features
of ADEM and pediatric MS are listed in Table 20.2.
Table 20.2
Differential Features of Pediatric MS and ADEM
ADEM Pediatric MS
Age at onset 3-7 y 12-15 y
Female:male
ratio
1:1 3:1
Symptoms Encephalopathy (lethargy,
obtundation, coma), polyfocal
neurological symptoms
Monofocal or polyfocal
neurological symptoms (such
as optic neuritis, transverse
myelitis, brainstem syndromes)
without encephalopathy
Disease
course
Symptoms can
fluctuate/appear within a 3-mo
period. Then generally remits
and remains monophasic
Polyphasic—new attacks or
new MRI lesions occurring
with separation in time by at
least 1 mo
CSF features WBC 50-70 (60%-70%
lymphocytes); no oligoclonal
bands
WBC 15-30 (90%-95%
lymphocytes); positive
oligoclonal bands in 70%-85%
MRI
features
Fluffy, diffuse lesions in the
subcortical white matter or
thalamus/basal ganglia.
Lesions can occur in other
areas including optic nerve,
brainstem, spinal cord
Periventricular lesions ovoid
discrete lesions. Involvement
of the corpus callosum. Lesions
can occur in other areas
including optic nerve,
brainstem, spinal cord
ADEM, acute disseminated encephalomyelitis; CSF,
cerebrospinal fluid; MRI, magnetic resonance imaging; MS,
multiple sclerosis; WBC, white blood cell.
Other similarly appearing white matter disorders include
neuromyelitis optica-spectrum disorder
6,10
and myelin
oligodendrocyte glycoprotein (MOG)-antibody-associated
disorders.
11-13
Testing for Aquaporin-4 antibody and MOG
antibodies should be sent in any child with an acute
demyelinating syndrome (ADS), and if negative, consider
repeating within a year or again for highly suspicious cases.
The differential diagnosis of pediatric MS is broad and
includes infectious, metabolic, and other autoimmune
disorders (Table 20.3). Red flags for a diagnosis other than
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pediatric MS include a progressive disease course from onset,
prominent seizures, rapid cognitive decline and headaches,
multisystemic involvement, onset before age 2 years, and
family history of severe neurological deficits.
Table 20.3
Differential Diagnosis of Pediatric MS
Category Specific Diseases
Autoimmune
conditions
Systemic lupus erythematosus
Behçet disease
Neurosarcoidosis
Isolated or primary angiitis of the CNS
Hemophagocytic lymphohistiocytosis
Autoimmune encephalitis (NMDAR antibody syndrome)
Hashimoto encephalopathy
Immunodeficiency
syndromes
XLP, NK
Infections Neuroborelliosis, progressive multifocal
leukoencephalopathy
Tumors Lymphoma, astrocytoma, glioma, oligodendroglioma,
ependymoma
Metabolic diseases
of the CNS
Leber hereditary optic neuropathy mitochondrial
syndromes biotin-responsive basal ganglia disease
Leukodystrophy ALD
Leukoencephalopathy with brainstem and spinal cord
involvement and lactate elevation (LSBL)
ALD, adrenoleukodystrophy; CNS, central nervous system;
NK, natural killer; NMDAR, N-Methyl D-aspartate receptor
antibody syndrome; XLP, X linked lymphoproliferative
syndrome.
Clinical Course of Pediatric MS
General Course
Over 95% of pediatric patients with MS present the relapsingremitting form of MS. The clinical course of children with MS
varies from patient to patient. 5 In general, children with MS
experience a higher relapse rate than most adult patients with
MS, with 2 to 3 times as many relapses.
14,15
Acute Attacks
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Relapses or attacks in pediatric MS include optic neuritis,
transverse myelitis, brainstem attacks, and cerebral attacks.
These can affect vision, cognition, motor function, sensation,
and bladder/bowel function, as well as pain and spasticity.
Relapses should be addressed promptly, and part of the
challenge in children can be recognition or reporting of a
relapse. Encouraging the patients to develop a good rapport
with parents and caregivers to alert them of new symptoms is
critical. Pseudorelapses, or those due to overheating, can
mimic a true relapse. General advice is that, if symptoms do
not remit with cooling down with cold drinks, air conditioning,
or antipyretics, then report to the neurologist or physician
immediately. Relapses are generally treated with a course of
intravenous steroids, which can reduce the severity and
duration of symptoms. Functional relapses in children with
MS have been reported. It is essential for the neurologist to
ascertain the consistency of relapse symptomatology and
consider this in the differential. 16 Most common preparations
are methylprednisolone at a dose of 15 to 30 mg/kg for 5 days
on average, but courses can range from 3 to 7 days depending
on symptom severity. Children may be admitted to the hospital
for a course of steroids, or if feasible and available, outpatient
infusion units or home infusion administration through a
visiting nurse can be used. Although studies have found highdose prednisone to be efficacious for relapse-treatment in
adults, this approach has not been studied in children. An oral
prednisone taper is generally administered after the first attack
of ADS, including in pediatric MS cases; however, it may not
be required for every attack, because avoidance of chronic
steroids can reduce steroid-related side effects.
Chronic Symptoms
More insidious or chronic symptoms include fatigue,
depression, 17 anxiety, cognitive decline, pain, spasticity, and
bladder/bowel dysfunction. These should be questioned and
addressed at each clinical visit. Treatment of fatigue can
include methylphenidate, modafinil, armodafinil, or
amantadine. Depression and anxiety should be addressed with
both counseling and potentially medicinal therapy. Referral for
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bladder issues may require a referral to a urologist. Pain may
be addressed with physical therapy or medical therapies.
Cognitive Deficits
Between one-third to two-thirds of pediatric patients with MS
may have significant cognitive deficits, including issues with
processing speed, information processing, memory deficits,
executive dysfunction, and lowered intelligence quotients, as
well as deficits in social cognition.
18,19
Evaluation and
monitoring by a neuropsychologist shortly after diagnosis is
important for evaluating for the presence of cognitive
dysfunction. A 504 or an individualized education plan (IEP)
plan should be instituted to address cognitive deficits and
ensure appropriate programming at school. This requires
interaction with the school and testing
neuropsychologist/neurologist. A guideline for a
comprehensive neuropsychological battery can be found in the
International Pediatric Multiple Sclerosis Study Group
(IPMSSG) publication.
General Management
Periodic visits to the neurologist every 4 to 6 months are
recommended to follow symptoms, response to treatment, and
psychosocial issues. These may be more frequent, or acute
visits may be needed at the time of a relapse. Additional
support from a pediatric psychologist/psychiatrist may be
required. Neuropsychological testing every 1 to 2 years is
generally recommended and can be used to inform the need
and details of an IEP. Symptomatic issues may require referral
to a pediatric physical therapist, physiatrist, urologist, and
other subspecialties as needed. Neuro-ophthalmology
examination may be required for evaluation and monitoring of
optic neuritis or ophthalmoplegias. 20 Visual rehabilitation may
be needed for children with severe visual deficits. MRI scans
of the brain, orbits, and spine should be completed at baseline
and repeated annually.
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