Bangladesh Journal of Neuroscience 2008; Vol. 24 (1) : 9-16 Initial Neurologic Symptoms Among Bangladeshi Multiple Sclerosis 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 nerve involvement, 64%), motor This study was undertaken in the weakness (92%), sphincteric disturbances Department of Neurology, Bangabandhu (92%) and a lower rate of brainstem and Sheikh Mujib Medical University (BSMMU), cerebellar involvement. Painful tonic Dhaka, from January 2002 to December spasm 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 disease 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 myelin 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. spinal cord 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 myelitis 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 ataxia, 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.