1. Int J MS Care 7:148-151, 2005/2006. Jan 9 & 10, 2007 1 Clinical Stabilization of a MS Patient after Tonsillectomy presented by Michael C. Levin, MD Department of Neurology Memphis VAMC Memphis, TN Terry Wren, RN January 9 & 10, 2007 VA MS Centers of Excellence

2. Int J MS Care 7:148-151, 2005/2006. Jan 9 & 10, 2007 2 Michael C. Levin, MD Department of Neurology Memphis VAMC Memphis, TN Terry Wren, RN reports that he has no relationships with commercial organizations to disclose.

3. Int J MS Care 7:148-151, 2005/2006. Jan 9 & 10, 2007 3 29 year old woman with RRMS referred for multiple relapses Relevant past neurological history 3 years earlier: –Paresthesias of lower extremities for 1 week 1 year later: –Symptoms recurred and ascended to thoracic area associated with change in gait –Upper respiratory infection (URI) 1 week prior to onset Neurological exam: –Lower extremity weakness –Subjective sensory level of T10 –No pathologic reflexes –Wide based, ataxic gait MRI of brain and spinal cord: –Cervical and thoracic cord MRI negative –Brain MRI shows multiple focal areas of increased signal intensity in corpus callosum and periventricular white matter CSF positive for oligoclonal bands Patient diagnosed with RRMS Patient treated with intravenous methylprednisolone 1000 mg/day for 5 days with prednisone taper Symptoms improved Patient started on interferon beta- 1a 30 mcg per week

4. Int J MS Care 7:148-151, 2005/2006. Jan 9 & 10, 2007 4 29 year old woman with RRMS referred for multiple relapses Neurological history –Documented 5 relapses in previous 10 months – each treated with methylprednisolone –Concurrent with each relapse she had an upper respiratory infection (URI) and sore throat for which she occasionally received antibiotics At time of referral: –1 week of pain and paresthesias of the left side of the face, numbness of right lower extremity that ascended to include the thoracic area & bilateral burning feet –6 th relapse in 10 months = 7.2 per year Neurological exam: –End gaze nystagmus –Numbness of left face –Decreased pinprick sensation from T12 – L1 on the right –Hyper-reflexia of lower extremities Medical exam: enlarged inflamed tonsils Refused IV steroids, treated with methylprednisolone dosepak MRI showed several new lesions, some enhancing (Figure 1 A) MRI spinal cord negative ENT evaluation shows chronic tonsillitis

5. Int J MS Care 7:148-151, 2005/2006. Jan 9 & 10, 2007 5 29 year old woman with RRMS referred for multiple relapses

6. Int J MS Care 7:148-151, 2005/2006. Jan 9 & 10, 2007 6 29 year old woman with RRMS referred for multiple relapses Patient underwent tonsillectomy: –3 weeks later felt ‘better’ but developed left sided numbness. Treated with IV methylprednisolone Restarted on interferon beta-1a 9 weeks post-op: –Normal neurological examination 13 months post-op: –One relapse treated with oral steroids –MRI improved –Annualized relapse rate of 1.85

7. Int J MS Care 7:148-151, 2005/2006. Jan 9 & 10, 2007 7 29 year old woman with RRMS referred for multiple relapses

8. Int J MS Care 7:148-151, 2005/2006. Jan 9 & 10, 2007 8 29 year old woman with RRMS referred for multiple relapses - discussion Infections are associated with increased risk of relapse and sustained disability –‘At Risk Periods – ARP’: defined as 2 weeks before the onset of a viral infection until 5 weeks post- infection Sibley et al., Lancet 1985: –Relapse rate 3X during ARP vs. non-ARP Anderson et al., J Neurol 1993: –Increased relapse rate during ARPs –correlation between URIs and more severe relapses Panitch et al., Ann Neurol 1994: –Relapse rate during ARPs = 2.92/year vs. 1.16 per year during non-ARPs (p<0.001) Rapp et al., Am J Phys Med Rehab 1995: –Increased risk of relapse associated with bacterial infections in hospitalized MS patients –Neurological improvement following aggressive treatment of the infection Buljevac et al., Brain 2002: –Increased risk of relapse and sustained neurological disability associated with ARPs

9. Int J MS Care 7:148-151, 2005/2006. Jan 9 & 10, 2007 9 29 year old woman with RRMS referred for multiple relapses - discussion In this study: –Patient’s relapses correlated with URIs –Diagnosed with pharyngo- tonsillitis –Before tonsillectomy: Annualized relapse rate of 7.2 –After tonsillectomy: Felt better Annualized relapse rate of 1.85 Improved brain MRI Tonsillectomy during childhood may be a risk factor for MS – now refuted (Poskanzer, Lancet, 1965. Broadly et al., Multiple Sclerosis 2000) Uncontrolled studies show that tonsillectomy may stabilize psoriasis – an immune disorder of skin (Wilson et al., Pediatr Dermatol, 2003) We could not find another study that showed stabilization of MS following tonsillectomy We suggest a thorough evaluation for infection in MS patients with multiple relapses We do not advocate use of routine tonsillectomy for MS