Common invisible symptoms of multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) a chronic inflammatory disease of central nervous system manifesting commonly as motor weakness, visual loss, diplopia, fatigue, bladder and bowel dysfunction and as sensory symptoms in limb or one half of face. These common symptoms are often tagged with many unpredictable, erratic or invisible symptoms which further complicates the clinical presentation and therefore management as well. Majority of these symptoms are subjective of varying degree which cannot be measured objectively to access the severity. Many such symptoms share the clinical profile of other diseases as well which further complicates and makes management of MS more challenging. It is critical that individuals with MS and their care takers should consider these symptoms because they may be unidentified, mis labelled or left untreated and allow the individual to be in denial about his/her MS and then necessity of beginning or continuing disease modifying treatment.¹

Increasing attention has been given to the invisible symptoms of MS in recent years, which can be defined as those symptoms that are life limiting but not readily discernible to others. MS may present with unusual manifestations such as pain syndrome, cognitive or psychiatric symptoms, movement disorders and rare cranial nerve involvement leading to difficult diagnostic dilemma.

Discussion of invisible symptoms in medical literature is limited. People with MS feel that invisibility of their illness created dilemmas for them, so physicians should not disregard MS when a patient present with any of the rare manifestations. Many invisible symptoms are reported by patients during their lifetime with MS.

BREATHING PROBLEMS

Difficulty in exhalation along with productive cough due to decreased lung capacity has been reported mainly in late stage of disease.

HEARING LOSS

Either intermittent or continuous hearing impairment is seen in approximately 6% to 8% people living with MS. It can even be a first symptom of MS. The development of plaque or scar in the course of auditory pathway is responsible for this. These hearing impairment episodes usually improve without any permanent deafness.

PRURITIS AND FACIAL NEURALGIA

Sudden severe itching lasting for a troublesome period may be less commonly seen along with other common symptoms of MS. There is generally no skin irritation or allergy to scratch. This kind of itch does not stem from skin rather this is neurologically based sensation that passes quickly (dysesthetic itch). It does not respond to tropical treatments like those used in allergic conditions. Similarly, patients experience a burning or stabbing unilateral facial or jaw pain like trigeminal neuralgia which can be a first symptom of MS. It responds well to drugs like carbamazepine, gabapentin and even phenytoin.²

TREMORS

Tremors which are provoked or intensified with movement (intention tremors) affecting various bodily parts at times raising the suspicion of extrapyramidal symptoms are also seen infrequently in MS patients. These tremors can affect any muscle groups of arm, leg, head, tongue, trunk or even vocal cords. The presence of tremors can add significantly to both fatigue and functional disability in MS and are difficult to manage as they poorly respond to the medication. Poor coordination or incoordination from cerebellar involvement coexists with tremors and makes the simplest of daily activities like walking, pouring liquids, eating and personal hygiene very difficult.³

EPILEPTIC SEIZURE

About 2% to 5% of patients with MS develop seizure activity of epileptic origin with serious consequences. The epilepsy may even present as an initial symptom of MS or a single clinical manifestation of a relapse. This further strengthens the assumption of existing relation between epilepsy and cortical-subcortical lesions in patients with MS. The commonest semiology of seizure is partial onset with secondary generalization. Simple partial seizures are about twice as common as complex partial seizures in patients with MS. This differs from general population where complex partial seizures are seen more frequently. The overall prognosis of seizure is usually good but the choice of antiepileptic drug remains a matter of debate as at times antiepileptics conversely worsen the symptoms of MS.^4,5

HEAT INTOLERANCE (UHTHOFF’S PHENOMENON)

The already frayed neurons in MS at times place havoc and makes these patients intolerant especially to high temperature. The addition of humidity further complicates the issue to the unbearable situation. At times small rise in body temperature worsens the already existing signs and symptoms. The demyelinated fibres in central nervous system become hyper sensitive to even small elevation of core body temperature resulting in conduction delay or even conduction block.⁶ This sensitivity can be brough out by sun bathing, exercise, hot burns, emotion, fatigue or any other factor associated with increase in core body temperature. These symptoms of heat intolerance generally disappear with rest and cooling and do not carry a long-term consequence. Similarly, extreme cold also had a deleterious effect and makes a patient uncomfortable and withdrawn.⁷

THE “MS HUG”

An extremely uncomfortable sensation around the muscles between the ribs manifesting as intense squeezing and crushing feelings (like a crushing hug) is essentially an assortment of pain in patients with active MS. The associated gripping, squeezing and constructing sensation is a manifestation of spasticity is sometimes accompanied by a component of respiratory limitation. Away from the warm and cosy feeling of hug, this unpleasant feeling can be associated with breathlessness and spasm. It often passes on its own.⁸

SLEEP ISSUES

Almost more than half of the patients in MS experience difficulty in sleeping mainly due to frequent nigh time urination, depression, spasticity, phenomenon of restless leg movements, obstructive sleep apnoea, periodically movement and difficulty in changing position in bed and poor sleep hygiene. Improper or inadequate sleep leads to fatigue which is the most common and one of the most debilitating symptoms of MS.^9,10

Restriction of night time liquid intake and avoidance of caffeinated drink and alcohol with medication and good sleep hygiene (with at least 8 hours of sleep) is the core-way to manage sleep related problem in these subset of MS patients.¹¹

SEXUAL DYSFUNCTION

Sexual dysfunction in MS is a troublesome situation leading to sexual inactivity in at least 50% of women with MS. The most common complaints are reduced libido, difficulties in achieving orgasm, decreased vaginal sensation and lubrication and dyspareunia.¹²

CONCLUSION

The people with MS are not protected from acquiring other illnesses or diseases. It is therefore important to evaluate the new or unusual symptoms to determine if they are a part of MS spectrum or caused by some other disease. But unusual and rare manifestation can be a part of the MS constellation of symptoms, so it is important to identify as these invisible or uncommon symptoms are experienced differently by these MS patients so tracking these symptoms is another way to manage MS more efficiently.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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