Clinical profile of multiple sclerosis in Bengal.

Gangopadhyay G, Das SK, Sarda P, Saha SP, Gangopadhyay P, Roy TN, Maity B
Department of Neuromedicine, Bangur Institute of Neurology and Institue of Postgraduate Medical Education and Research, Calcutta, Bengal, India.

Correspondence Address:
Department of Neuromedicine, Bangur Institute of Neurology and Institue of Postgraduate Medical Education and Research, Calcutta, Bengal, India.

»   Introduction

However, the prevalence rate has increased consequent to use of modern investigative facilities and increased awareness.[2] Optic nerve and spinal cord involvement, with predominant visual impairment in the beginning are more common in the Asian variety.[3] Many studies are available from western,[4] northern[5],[6] and the south India,[7],[8],[9] however, there has been no report from the eastern part of the country. The aim of our study is to note the clinical pattern and course of MS in West Bengal on a retrospective and prospective basis.

»   Material and methods

Records of 31 patients admitted in the last 10 years under the Department of Neuromedicine, Bangur Institute of Neurology and Institute of Postgraduate Medical Education and Research, Calcutta, were analysed. 14 cases registered in the east-zone unit of Multiple Sclerosis Society of India were prospectively analysed. Relevant investigations were undertaken to diagnose MS and to exclude other conditions. ESR, blood biochemistry comprising blood sugar urea, creatinine, cholesterol, VDRL, and collagen profile was studied. Mantoux test and chest X-ray (PA view) were also done. CSF-cytology, biochemistry, VDRL, AFB smear, oligoclonal band and immunoglobin index estimation were done wherever possible. CT scan of the brain was done in most of the cases. MRI of brain or spinal cord and evoked potential studies were performed wherever patient could afford them.

The cases were diagnosed according to Poser's diagnostic criteria[10] and were followed up periodically for reassessing their status. No case of Devic's disease was included.

»   Results

The patients were categorized as definite or probable MS, after taking proper history, thorough clinical examination and relevant laboratory investigations including imaging studies. The incidence of MS was 0.32% of all hospital admissions and 0.62/100,000 of neurology clinic patients. The mean age of onset was 31.83 years in males and 29.11 years in females. The youngest patient was 15 years and the oldest 55 years of age. Maximum number of cases were found in the 3rd and 4th decades. Male : female ratio was 1:15 and the proportion of definite and probable cases of MS in this study was 60% and 40% respectively.

[Figure 1] shows the frequency of initial presenting symptoms and its comparison to two Indian studies, one Asian and another western study. Visual impairment was the commonest presentation (33.33%). 71% of patients had visual impairment sometime during the illness. Limb weakness (82.22%), sensory paraesthesia (75.55%) and visual impairment (71.11%) were the commonest symptoms during the course of illness in order of decreasing frequency, in the present study.

[Figure 2] shows the sites of involvement of CNS in five series. In the present series, pyramidal tract followed by optic nerve, brain system and cerebellum were involved in decreasing order of frequency. Optico-brainstem-cerebello-spinal (26.66%) and optico-spinal (22.22%) were common patterns of involvement.

Remitting and relapsing pattern was the commonest presentation (48.91%) followed by relapsing and progressive (33.33%) and chronic progressive varieties (17.81%). Rise of protein and pleocytosis was seen in 83% and 46.67% of cases respectively. Positivity rate was highest for IgG estimation (73.3%) as compared to oligoclonal band, which was seen in 11 of 36 cases (31%).

Table I indicates the neuroimaging and eletrophysiological studies. MRI was positive in 69.56%. Among electro physiological studies, VEP was found to be positive in 100% of symptomatic cases.

»   Discussion

Multiple sclerosis is less common in tropical countries. Three neuroepidemiological studies from different parts of India[11],[12],[13] did not document any case of multiple sclerosis. This may be due to varying course of the disease. Consideration of illness as insignificant by the patients or reluctance on the part of the treating doctor to consider the diagnosis of MS because of low frequency may be contributory factors for reported lower incidence.[1] In view of lack of epidemiological data, most studies on MS are based on hospital data which has shown that MS constitutes 0.05% of the hospital admissions in the south [14] to 1.58% in the north.[5] The present study documents 0.32% of hospital admissions, which correlates well with another report from south[8] and north.[15] Thus the frequency of MS in the east is the same as in any other part of India. The disease has been well documented after MRI became available.

Present study has documented male : female ratio of 1:1.5. Five studies[4],[5],[8],[9],[15] have shown male preponderance (range 1.25-2) and one study[14] has shown female predominance. Kurtzke et al[16] have, however, shown female predominance (female:male-1.8:1) among US veterans. Predominant male dominance in health seeking behaviour in India may explain the above sex difference.[17] Mean age of presentation was 31.83 years in men and 29.11 years in women in the study which is slightly higher than that reported by Singhal and Wadia[4] and Bhatia et al.[6] The youngest and oldest case reported in the present study was 15 years and 55 years old.

Though MS in India is not different from the western variety,[6] an increased frequency of visual involvement is a common feature in Asian variety.[3],[4],[18] In this study, visual impairment was the commonest initial symptom (33%) followed by weakness of the limbs (31%) and sensory paraesthesia (20%). This feature correlates well with the earlier observation from India[4]and Japan.[18] However, other studies from India[6],[7] documented weakness as the commonest initial presentation similar to western pattern.[16] Motor weakness, visual impairment, sensory disturbances es, ataxia and sphincter involvement were the commonest symptoms in various series.[4],[6],[16],[18] Visual impairment in Japanese and ataxia in western reports were relatively more commoner than Indian series.

Seizures are uncommon presentation of MS and were noted in two patients (4.44%) in the present series. One of them had focal seizure. Another patient presented with encephalopathic picture with normal CT scan. Subsequent course of the disease raised suspicion of multiple sclerosis and relevant investigations confirmed the diagnosis of multiple sclerosis and relevant investigations confirmed the underlying diagnosis. Singhal and Wadia reported seizure disorder in 3.33% of the cases in their series.[4] Seizure disorder is uncommon in multiple sclerosis but has been reported to be commoner than the general population. Underlying cause for epilepsy has been related to extension of subcortical demyelinating plaque to the cortex. Internuclear ophthalmoplegia (INO) was seen in 3 cases (6.66%) in the present series. This has not been mentioned in the series reported by Singhal[4] and Bhatia.[6] Pandit et al however reported one case of INO in their series.[7] Optico-brainstem-cerebello-spinal involvement was the commonest (26.66%) presentation. Optico spinal affection represented 22.22% of cases Kuroiwa and Kurland[3] and Singhal and Wadia[4] also found involvement of optic-spinal-brain stem-cerebellar sites among their patients.

CT scan showed abnormal finding in 14.2% of cases. This figure is much lower than the earlier report by Maheshwari et al[19] who recorded abnormal findings in 31% CT scan. This may be due to our patients being scanned by first generation CT scan with low resolution. Presently, with clinical suspicion of MS, usually MRI is advised. Still, in the present study, positivity of MRI is much lower than the western report which revealed abnormal MRI in 88% to 99% of cases.[20] Inadequate exploration of other parts e.g. lack of brain imaging in cases with myelopathic presentation[21] may be responsible for the lower incidence.

In conclusion, the results of this study are similar to the observations in other parts of India. However, this study conforms more to the `Asian variety' of multiple sclerosis. We noted an atypical `encephalopathic' presentation of MS among our cases. CSF IgG estimatiom has proved to be more useful than oligoclonal band estimation alone.

»   Acknowledgement

We are deeply obliged to the Director, Bangur Institute of Neurology, Superintendent,S S K M hospital, Prof Shyamal Sen, Chairman of Eastern Zonal Multiple Sclerosis Society for giving permission to use the case materials.

 

»   References

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