Bangladesh Journal of Neuroscience 2008; Vol. 24 (1) : 9-16 Initial Neurologic Symptoms Among Bangladeshi Patients MD BAHADUR ALI MIAH1, ABDUL KADER SHEIKH1, AKHLAQUE HOSAIN KHAN2, MD RAFIQUL ISLAM3, AKM ANWAR ULLAH4, QUAZI DEEN MOHAMMAD5, ANISUL HAQUE4

Abstract vision (optic involvement, 64%), motor This study was undertaken in the weakness (92%), sphincteric disturbances Department of , Bangabandhu (92%) and a lower rate of brainstem and Sheikh Mujib Medical University (BSMMU), cerebellar involvement. Painful tonic Dhaka, from January 2002 to December was a prominent feature among 2003. The objective of this study was to Bangladeshi patients with multiple sclerosis determine the initial neurologic symptoms (8 out of 25, 32%). of multiple sclerosis among Bangladeshi Out of 25 patients, one (4%) expired due patients. to aspiration pneumonia. Twenty four (96%) A total of 25 respondents of multiple survived. Among them 9 (36%) has sclerosis patients as cases selected by restricted activity, 7 (28%) were bedridden, McDonald et al. (2001) diagnostic criteria 5 (20%) were chairbound, 2 (8%) had minor disability and were in work and 1 (4%) was for multiple sclerosis were enlisted during completely normal. the study period. The clinical details, investigations of the respondents were Introduction reviewed. Data were recorded in Multiple sclerosis (MS) is an inflammatory predesigned data collection sheet. Out of demyelinating of central nervous 25 cases, male patients were 12 (48%) and system (CNS) causing significant morbidity females were 13 (52%), ratio being 1:1.08. with a variable course, thought to result from Majority of the patients presented at immune response to sheath with second, third and fourth decades of life. variability in frequency. It typically presents Most of the patients (56%) had acute onset, between the ages of 18 and 45 years, followed by subacute (28%) and insidious although the true onset of the disease likely (16%). Certain clinical characteristics predates the initial symptoms in most 1 among Bangladeshi multiple sclerosis individuals . patients are noteworthy, namely, number Multiple sclerosis is more frequently of male and female patients almost equal encountered in western countries and is (48% vs 52%), a higher rate of impaired distinctly unknown in certain ethnic and

1. Assistant Professor, Department of Neurology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka. 2. Assistant Professor, Department of Neurosurgery, BSMMU, Dhaka. 3. Associate Professor, Department of Neurology, BSMMU, Dhaka. 4. Professor, Department of Neurology, BSMMU, Dhaka. 5. Professor and Head, Department of Neurology, Dhaka Medical College and Hospital, Dhaka.

. racial groups, such as Eskimos, Native Aims and Objectives Americans, Indians and Africans2. The Many studies are available from other variation in prevalence of MS according to countries of Asia, especially from Japan, geographical location and the modification Saudi Arabia and India. There has been no of clinical picture by ethnic groups are all study from Bangladesh. The aims of this well known features of the disease3. study was to find out and describe the initial Current estimates suggest that the symptoms of multiple sclerosis and prevalence in the United States is compare the observed clinical features approximately 350,000 with an annual between Bangladeshi MS patients with incidence of about 12,0004. Prevalence is those of the western MS patients. low in Saudi Arabia and other Arab Middle Materials and Methods Eastern countries with rates varying This prospective study was carried out in between 4 and 12 per 100,000 inhabitants5- the Department of Neurology, Bangabandhu 7. In contrast amongst Caucasians rate is Sheikh Mujib Medical University (BSMMU), as high as 309 per 100,000 have been Dhaka, among both indoor and outdoor reported8,9. It was thought that MS was patients, during the period of January 2002 uncommon in Bangladesh and other to December 2003. A total number of 25 tropical and sub-tropical countries10-12. patients were assessed, investigated and Susceptibility is also associated with diagnosed having MS during the study period, who fulfilled the McDonald’s particular genetic factor, such as HLA-DR2, 23 and there are documented differences in diagnostic criteria for multiple sclerosis . Caucasians and Orientals with MS patients Patients with recent vaccination and/or viral in terms of HLA association and oligoclonal infection, patients suffering from systemic bands (OCBs)13-15. lupus erythematosus (SLE), Rheumatoid arthritis (RA), sarcoidosis and other There have been relatively a few studies collagen vascular disease, neoplasm, 16 from Asia, India and in particular no study cervical spondylosis and metabolic from Bangladesh. Asian MS has disorders were excluded from the study. traditionally been thought of as a distinct Clinical diagnosis of MS patients was based entity characterized by optic nerve and on medical history and clinical examination. involvement, with predominant Confirmation of clinical diagnosis was done visual involvement in the beginning being by available relevant investigations, 17 more common and less frequent specially MRI of brain and/or spinal cord 18-22 involvement of cerebellum . with contrast when required. Necessary Clinical pattern of multiple sclerosis in laboratory procedures were done to Bangladesh is unknown. However, the ascertain exclusion criteria. detection of MS have increased as a Informed consents were taken from each consequence of use of modern investigative patient before his/her inclusion in the study. facilities, particularly with the availability of All relevant information from history, clinical MRI facilities, increased awareness among findings and investigations were medical professionals and patients. documented in predesigned data collection

10 sheet. Patients were seen every three The lesions at initial onset are shown in months interval or as required in the Table III. Sixteen (64%) patients out of 25 Department of Neurology, BSMMU, and had optic neuritis as their first symptom. subsequent data recorded in the data Five (20%) patients had optic neuritis alone. collection sheet. Data collected were Seven (28%) patients had optic nerve and compiled in a master sheet and required brain, 4 (16%) patients had optic nerve and analyses were done using computer based spinal cord involvement at onset. Seven software SPSS (Statistical Package for (28%) patients had alone, 1 (4%) Social Science). had spinal cord and brain involvement, and Results 1 (4%) had only brain involvement. The age range of 25 patients of MS was 10 Table-III 65 years, with mean (±SD) 30.56±13.44 Lesions at initial onset among years. The study included 8 (32%) cases Bangladeshi multiple sclerosis < 20 years, 12 (48%) cases between 21 patients (n=25) 40 years, 4 (16%) cases between 41-60 years and 1 (4%) case above 60 years. First involvement Number of Percentage patients The peak age of incidence of MS was found Only optic nerve 5 20.0 in 21-40 years age group (Table I). Optic nerve + brain 7 28.0 Table-I Optic nerve + spinal cord 4 16.0 Only spinal cord 7 28.0 Age distribution of the study Spinal cord + brain 1 4.0 subjects (n=25) Brain alone 1 4.0 Optic nerve involvement (n=16) Age group Number of Percentage Unilateral 8 50.0 (years) patients Bilateral 8 50.0 < 20 8 32.0 21-40 12 48.0 Table IV shows mode of onset among the study subjects. Out of 25 cases, 14 (56%) 41-60 4 16.0 had acute onset, 7 (28%) subacute onset >60 1 4.0 and 4 (16%) chronic or insidious onset. Total 25 100 Table IV Out of 25 patients of MS, 12 (48%) were Multiple sclerosis typing (according to male and 13 (52%) were female. The male mode of onset) (n=25) female ratio was 1:1.08 (Table II). Mode of onset Number of Percentage Table II patients Sex distribution of the cases (n=25) Acute 14 56.0 Sex Number of Percentage Subacute 7 28.0 patients Chronic/insidious 4 16.0 Male 12 48.0 Total 25 100 Female 13 52.0 In Table V, the number of previous attack Total 25 100 has been shown. Out of 25 patients, 5

11 (20%) had one, 8 (32%) had two and 5 20 (80%) had rigidity of their limbs. (20%) had more than two previous attacks. Sensory symptoms, like numbness and Seven (28%) patients had no history of paresthesia, diminished or loss of previous attack. sensation, were found in following order Table-V respectively (84%, 60% and 4%). Impaired Distribution of the respondents by vision was found in 16 (64%) cases. Seven number of previous attacks (n=25) (28%) cases had pain in their eyes. Symptoms like , sphincteric Previous attacks Number of Percentage disturbance, paroxysmal attack were found patients in a large number of patients {8 (32%), 23 One 5 20.0 (92%), 8 (32%), respectively}. Two 8 32.0 Table-VII More than two 5 20.0 Clinical presentation (n=25)

None 7 28.0 Presentation Number of Percentage Total 25 100 patients Weakness Table VI shows the course of the disease Upper + lower limb 10 40.0 among the respondents. Fifteen (60%) Only lower limb 13 52.0 Only upper limb 0 0 cases had relapsing remitting course, 7 No weakness 2 8.0 (28%) had secondary progressive course Rigidity 20 80.0 and 3 (12%) had primary progressive Sensory function multiple sclerosis. Diminished 15 60.0 Lossed 1 4.0 Table-VI Normal 9 36.0 Distribution of the cases according to Numbness/paresthesia 21 84.0 Impaired vision 16 64.0 course of the disease (n=25) Both eyes 8 32.0 Only left eye 3 12.0 Disease course Number of Percentage Only right eye 5 20.0 patients Pain in the eyes Only right eye 1 4.0 Relapsing 15 60.0 Only left eye 1 4.0 remitting MS Both eyes 5 20.0 Diplopia 1 4.0 Secondary 7 28.0 Ataxia 8 32.0 progressive MS Urinary Sphincteric 23 92.0 Disturbance Primary 3 12.0 Urgency 7 28 progressive MS Incontinence 5 20 Retention 5 20 Total 25 100 Frequency 3 12 Hesitancy 3 12 The clinical presentations are summarized Paroxysmal attack 8 32.0 (painful tonic spasm) in Table VII. Out of 25 study cases, 23 (92%) had motor weakness, 10 (40%) had Functional status of the study patients has both upper and lower limbs weakness, 13 been shown in Table VIII. Nine (36%) (52%) had only lower limbs involvement, patients had restricted activities, 7 (28%)

12 were bedridden, 3 (12%) were chairbound, selected by McDonald et al. diagnostic 4 (16%) suffered only minor disabilities and criteria for multiple sclerosis23. Clinical were still in work, and 1 (4%) had died. examination and laboratory investigations Table-VIII were done in all patients. Present functional status (n=25) In this study, 12 (48%) patients were male and 13 (52%) were female (ratio 1:1.08). Function Status Number of Percentage There was no marked female patients preponderance like other countries. The Restricted activity 9 36.0 male female ratio in various countries are - Bedridden 7 28.0 USA 1:1.826, Northern Ireland 1:1327, US Chairbound 3 12.0 army 1:1.828, Japan 1:1.329, Taiwan Minor disability 4 16.0 1:3.230, Hawaii 1:3.231, India 1:332 and Normal activity 1 4.0 Thailand 1:325. The male female ratio is Expired 1 4.0 higher in our country than western and Total 25 100 oriental countries. Predominant male health seeking behaviour and also less Discussion allocation of hospital beds for female Multiple sclerosis is an uncommon condition patients in country may explain the above. in Bangladesh, and its prevalence, These findings are not consistent with those incidence and other demographic data of Acheson, who previously pointed out that remains to be determined. So far my the preponderance of female over male knowledge goes no study has yet been patients seemed to be greater where the published on multiple sclerosis in incidence of multiple sclerosis was low than Bangladesh. The present study disclosed where it was high27. that certain clinical features of multiple We did not find any familial case. This sclerosis patients are different from those may be because of multiple sclerosis began of multiple sclerosis patients in western to be diagnosed during last few years in countries, but the age distribution in our country, and general population has no Bangladeshi multiple sclerosis patients idea about this disease. were not significantly different from those of western and other Asian countries24,25. With regard to initial lesion, this study showed that optic neuritis (16/25, 64%) was The present study was carried out to find common initial lesion among the out the initial symptoms of multiple Bangladeshi multiple sclerosis patients. sclerosis among Bangladeshi patients. Five (20%) patients had optic neuritis alone, The study subjects were taken from the seven (28%) had optic nerve and brain Department of Neurology (both indoor and involvement, four (16%) had optic nerve and outdoor), Bangabandhu Sheikh Mujib spinal cord involvement. It was 43% in Medical University (BSMMU), Dhaka. Japanese nationwide series, 14% in Israel, During the study period, from January 2002 43% in Brazil, 36% in Germany, 56% in to December 2003, 25 multiple sclerosis Taiwan, 28% among UK army and 25% in patients were evaluated. Patients were the USA24,30,33-35.

13 Optic neuritis was lower than Thai series Shibasaki and Kuroiwa39 found the (68%) as shown by Jitpimolmard and condition in 11 (17.2%) patients out of a Vejjajivaas25, which is almost equal to consecutive series of 64 patients with Korean patients, where it was 64%36. It is multiple sclerosis, a much higher incidence interesting that the incidence of optic than has been found in western countries28. neuritis when combined with spinal cord In Thailand, Jitpimolmard and Vejjajiva25 and brain involvement, it was even higher observed no less than 3 in 15 patients with among Bangladeshi patients. Though multiple sclerosis. It appears, therefore, multiple sclerosis is not different from the that PTS is relatively frequent among western variety, an increased frequency of multiple sclerosis patients in Bangladesh visual involvement is a common feature in and in Asian countries where cases with Asian variety32. Seven (28%) patients had severe spinal cord involvement are more only spinal cord involvement presented frequently encountered. initially as myelitis, which is comparable Conclusion in percentage with the other series Multiple sclerosis is a leading neurological (28.46%)37. disease causing chronic disability in young The frequency of brainstem and cerebellar adults, especially in western countries, lesions were much lower than the US army, which might cost a large amount of money Brazil, USA, Japan, China and Taiwan. each year. This is because of the use of brainstem It has been established that multiple evoked potential in developed countries that sclerosis in Bangladesh exhibits some unmasked the silent lesion in the brainstem. clinical difference in its initial neurological Twenty three (92%) patients developed symptoms from those of western countries weakness of the limbs. It is much higher but not from most of the Asian countries, 35 24 than Germany (43%) , USA (54%) , which may be due to racial, genetic and 34 30 Japan (24%) and Taiwan (40%) series. environmental influences. This is because that our patients usually presents late in the disease course. References 1. Frohman EM. Multiple sclerosis. Sphincteric abnormalities in the present Med N Am 2003; 867 -97, viii-ix. group differs extensively from reported 2. Minderhoud JM, van der Hoeven JH, series in other countries. It was 22% in Prange AJ. Course and prognosis of Brazil38, 10% in Germany35, 30% in the chronic progressive multiple sclerosis: USA24, 4% in Taiwan30 and 23% in results of an epidemiological study. Korea36. Acta Neurol Scand 1988; 78:10-15. One of the striking feature of this study was 3. Kurland LT. The epidemiologic the high incidence of painful tonic characteristics of multiple sclerosis. (PTS), specially in cases with severe spinal In: Vinken PJ, Bruyn GW, editors. cord involvement. This phenomenon was Handbook of clinical neurology. seen in 8 (32%) patients out of 25 multiple Amsterdam: North Holland Publishing sclerosis cases. Co., 1970: pp 63-84.

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