Immune Disorders

Multiple Sclerosis
Multiple sclerosis (MS) is a potentially disabling disease of the brain and spinal cord
(central nervous system).
In MS, the immune system attacks the protective sheath (myelin) that covers nerve
fibers and causes communication problems between your brain and the rest of your
body. Eventually, the disease can cause permanent damage or deterioration of the
nerves.
Signs and symptoms of MS vary widely and depend on the amount of nerve damage
and which nerves are affected. Some people with severe MS may lose the ability to
walk independently or at all, while others may experience long periods of remission
without any new symptoms.
There's no cure for multiple sclerosis. However, treatments can help speed recovery
from attacks, modify the course of the disease and manage symptoms.

Manifestation
Multiple sclerosis signs and symptoms may differ greatly from person to person and
over the course of the disease depending on the location of affected nerve fibers.
Symptoms often affect movement, such as:
 Numbness or weakness in one or more limbs that typically occurs on one side of
your body at a time, or your legs and trunk
 Electric-shock sensations that occur with certain neck movements, especially
bending the neck forward (Lhermitte sign)
 Tremor, lack of coordination or unsteady gait
Vision problems are also common, including:
 Partial or complete loss of vision, usually in one eye at a time, often with pain
during eye movement
 Prolonged double vision
 Blurry vision
Multiple sclerosis symptoms may also include:
 Slurred speech
 Fatigue
 Dizziness
 Tingling or pain in parts of your body
 Problems with sexual, bowel and bladder function

Laboratory Needed
Although there is no single test or set of tests that can establish a diagnosis of multiple
sclerosis (MS), there are three tests that are generally considered useful:
 Magnetic resonance imaging (MRI)
 Visual evoked potentials (VEP)
 Cerebrospinal fluid (CSF) analysis
Laboratory tests
There are no laboratory tests that are completely specific for MS, but several laboratory
tests are helpful in diagnosing or excluding this disease as the cause of a person’s
signs and symptoms. A few involve tests done on cerebrospinal fluid:
 CSF Electrophoresis and Isoelectric Focusing—these are two methods for
separating the proteins in a biological fluid. A patient’s CSF and serum are
evaluated side-by-side. Following the separation step, a protein stain is applied
to both specimens and the banding patterns that appear in the CSF and serum
are compared. The presence of two or more IgG bands in CSF that are not
present in serum is a positive test for oligoclonal banding. About 90% of people
with MS show oligoclonal banding in their CSF.
 CSF Immunoglobulin G (IgG) Index—increased levels of CSF IgG can be due to
excess production of IgG within the central nervous system, which is seen with
MS and several other diseases. It can also be due to leakage of plasma proteins
into the CSF, such as might occur with inflammation or trauma. To discriminate
between these two possibilities, the IgG index is calculated from IgG
and albumin measurements performed in CSF and serum:
IgG index = [IgG (CSF) / IgG (serum)] / [Albumin (CSF) /Albumin (serum)]
An elevated IgG index indicates increased production of IgG within the central nervous
system. It is found in about 90% of MS cases.
 Myelin basic protein—this is a major component of myelin. Increased
concentrations of myelin basic protein in CSF indicate that demyelination is
taking place. This process is not specific for MS, as other inflammatory diseases
of the central nervous system can also elevate the amount of myelin basic
protein in CSF. This test is not widely available; however, it may be used to
assess disease activity in cases of established MS.
Healthcare practitioners may also test for diseases that can cause symptoms similar to
MS to determine if they may be responsible for a patient’s illness. Examples include:
 Lyme disease
 Syphilis
 HIV
 HTLV
 Vitamin B12 deficiency
 Autoimmune disorders (e.g., lupus)
 Sarcoidosis
 Vasculitis
Non-laboratory tests
  MRI (magnetic resonance imaging) scans allow healthcare practitioners to
examine the brain, spinal cord, and optic nerve. MRI can show both permanent
CNS scarring as well as new lesions. These scans are used to help diagnose MS
and to track its progression over time. Improvements in MRI technology have
significantly improved the ability to accurately diagnose MS at an early stage.
Early diagnosis and treatment is key to minimizing the effects of the disease.

In addition to the standard MRI, there are a variety of specialized techniques that may
be performed, such as functional MRI, magnetic resonance spectroscopy, and diffusion-
tensor MRI. The National Multiple Sclerosis Society (NMSS) web site has more
information on the use of MRI in MS.
 Visual Evoked Potentials (VEP) are electrical diagnostic tests that measure the
speed of nerve transmissions (messages) in various parts of the brain. They
record the nervous system’s electrical response to visual stimuli. Damage to
myelin can slow nervous system response time and VEP tests can reveal
evidence of scarring along nerve pathways associated with vision. The NMSS
web page has additional details about this test.

Two other types of evoked potentials may be used, though less commonly: (1)
Brainstem Auditory Evoked Potentials (BAEP) is a test that helps detect lesions in the
brainstem causing delays in the transmission of sounds, and (2) Somatosensory
Evoked Potentials (SSEP) is a test that applies a brief electrical stimulus to the wrist or
ankle. It detects disruptions in the pathways from the arms and legs to the brain at very
specific points of the CNS.
Although there is no single test or set of tests that can establish a diagnosis of multiple
sclerosis (MS), there are three tests that are generally considered useful:

Magnetic resonance imaging (MRI)

Visual evoked potentials (VEP)
Cerebrospinal fluid (CSF) analysis
Laboratory tests
There are no laboratory tests that are completely specific for MS, but several laboratory
tests are helpful in diagnosing or excluding this disease as the cause of a person’s
signs and symptoms. A few involve tests done on cerebrospinal fluid:

CSF Electrophoresis and Isoelectric Focusing—these are two methods for separating
the proteins in a biological fluid. A patient’s CSF and serum are evaluated side-by-side.
Following the separation step, a protein stain is applied to both specimens and the
banding patterns that appear in the CSF and serum are compared. The presence of two
or more IgG bands in CSF that are not present in serum is a positive test for oligoclonal
banding. About 90% of people with MS show oligoclonal banding in their CSF.
CSF Immunoglobulin G (IgG) Index—increased levels of CSF IgG can be due to excess
production of IgG within the central nervous system, which is seen with MS and several
other diseases. It can also be due to leakage of plasma proteins into the CSF, such as
might occur with inflammation or trauma. To discriminate between these two
possibilities, the IgG index is calculated from IgG and albumin measurements
performed in CSF and serum:
IgG index = [IgG (CSF) / IgG (serum)] / [Albumin (CSF) /Albumin (serum)]

An elevated IgG index indicates increased production of IgG within the central nervous
system. It is found in about 90% of MS cases.

Myelin basic protein—this is a major component of myelin. Increased concentrations of

myelin basic protein in CSF indicate that demyelination is taking place. This process is
not specific for MS, as other inflammatory diseases of the central nervous system can
also elevate the amount of myelin basic protein in CSF. This test is not widely available;
however, it may be used to assess disease activity in cases of established MS.
Healthcare practitioners may also test for diseases that can cause symptoms similar to
MS to determine if they may be responsible for a patient’s illness. Examples include:

Lyme disease
Syphilis
HIV
HTLV
Vitamin B12 deficiency
Autoimmune disorders (e.g., lupus)
Sarcoidosis
Vasculitis
Non-laboratory tests

MRI (magnetic resonance imaging) scans allow healthcare practitioners to examine the
brain, spinal cord, and optic nerve. MRI can show both permanent CNS scarring as well
as new lesions. These scans are used to help diagnose MS and to track its progression
over time. Improvements in MRI technology have significantly improved the ability to
accurately diagnose MS at an early stage. Early diagnosis and treatment is key to
minimizing the effects of the disease.

In addition to the standard MRI, there are a variety of specialized techniques that may
be performed, such as functional MRI, magnetic resonance spectroscopy, and diffusion-
tensor MRI. The National Multiple Sclerosis Society (NMSS) web site has more
information on the use of MRI in MS.

Visual Evoked Potentials (VEP) are electrical diagnostic tests that measure the speed of
nerve transmissions (messages) in various parts of the brain. They record the nervous
system’s electrical response to visual stimuli. Damage to myelin can slow nervous
system response time and VEP tests can reveal evidence of scarring along nerve
pathways associated with vision. The NMSS web page has additional details about this
test.

Two other types of evoked potentials may be used, though less commonly: (1)
Brainstem Auditory Evoked Potentials (BAEP) is a test that helps detect lesions in the
brainstem causing delays in the transmission of sounds, and (2) Somatosensory
Evoked Potentials (SSEP) is a test that applies a brief electrical stimulus to the wrist or
ankle. It detects disruptions in the pathways from the arms and legs to the brain at very
specific points of the CNS.

Treatment and Prevention

There is no cure for multiple sclerosis, but a variety of treatments are available that may
be used to manage the condition. The goals of MS treatment are to slow the
progression of the disease, relieve symptoms, and minimize the effects of acute attacks.

Several medications have been approved by the U.S. Food and Drug Administration
(FDA) to help reduce the severity of the disease and slow progression. These are useful
for many people with relapsing forms of MS. (For details, see the National Multiple
Sclerosis Society webpage on Medications.)
Healthcare practitioners may prescribe corticosteroids for short periods of time to help
reduce inflammation and shorten the duration of relapses.
Other medications may be used to address specific symptoms, such as bladder and
bowel problems, tremors, dizziness, pain, and problems walking, to name a few.
Fatigue and depression sometimes associated with MS, for example, may be treated
with appropriate antidepressants.
Physical therapy, exercise, and avoiding heat are also important measures.
For more on specific medications that may be prescribed, see the Treatments page on
the National Multiple Sclerosis Society website.

MS does not significantly decrease the lifespan of those who have it, but it can
frequently and intermittently affect quality of life. While the vast majority of patients are
mildly affected, the worst cases can render a person unable to write, speak, or walk.
People with MS usually work with a team of professionals who help support and monitor
their condition and address their changing needs. Current MS research is directed
toward understanding the cause of MS in hopes of developing better drugs to treat, if
not cure or prevent the disease.

Type 1 Diabetes Mellitus

Type 1 diabetes is a disease in which the body does not make enough insulin to control
blood sugar levels. Type 1 diabetes was previously called insulin-dependent diabetes or
juvenile diabetes.
During digestion, food is broken down into basic components. Carbohydrates are
broken down into simple sugars, primarily glucose. Glucose is a critically important
source of energy for the body’s cells. To provide energy to the cells, glucose needs to
leave the blood and get inside the cells.
Insulin traveling in the blood signals the cells to take up glucose. Insulin is a hormone
produced by the pancreas. When levels of glucose in the blood rise, like following a
meal, the pancreas normally produces more insulin.
Type 1 diabetes occurs when some or all of the insulin-producing cells in the pancreas
are destroyed. This leaves the patient with little or no insulin. Without insulin, sugar
accumulates in the bloodstream rather than entering the cells. As a result, the body
cannot use this glucose for energy. In addition, the high levels of glucose that remain in
the blood cause excessive urination and dehydration, and damage tissues of the body.
Type 1 diabetes is an autoimmune disease. This means it begins when the body’s
immune system attacks cells in the body. In type 1 diabetes, the immune system
destroys insulin-producing cells (beta cells) in the pancreas.
Why the immune system attacks the beta cells remains a mystery. Some people are
genetically predisposed to the disease. That does not mean they will necessarily get the
disease. It just means that they are more likely to do so. Something in the environment,
such as particular viral infections or something about the diet, may trigger this
autoimmune disease in people with a genetic predisposition.
Type 1 diabetes is not caused by the amount of sugar in a person’s diet before the
disease develops.
Type 1 diabetes is a chronic disease. It is diagnosed most commonly between ages 10
and 16. Type 1 diabetes equally affects males and females.

Manifestation
Over time, type 1 diabetes complications can affect major organs in your body, including
heart, blood vessels, nerves, eyes and kidneys. Maintaining a normal blood sugar level
can dramatically reduce the risk of many complications.
Eventually, diabetes complications may be disabling or even life-threatening.
Heart and blood vessel disease. Diabetes dramatically increases your risk of various
cardiovascular problems, including coronary artery disease with chest pain (angina),
heart attack, stroke, narrowing of the arteries (atherosclerosis) and high blood pressure.
Nerve damage (neuropathy). Excess sugar can injure the walls of the tiny blood vessels
(capillaries) that nourish your nerves, especially in the legs. This can cause tingling,
numbness, burning or pain that usually begins at the tips of the toes or fingers and
gradually spreads upward. Poorly controlled blood sugar could cause you to eventually
lose all sense of feeling in the affected limbs.
Damage to the nerves that affect the gastrointestinal tract can cause problems with
nausea, vomiting, diarrhea or constipation. For men, erectile dysfunction may be an
issue.
Kidney damage (nephropathy). The kidneys contain millions of tiny blood vessel
clusters that filter waste from your blood. Diabetes can damage this delicate filtering
system. Severe damage can lead to kidney failure or irreversible end-stage kidney
disease, which requires dialysis or a kidney transplant.
Eye damage. Diabetes can damage the blood vessels of the retina (diabetic
retinopathy), potentially causing blindness. Diabetes also increases the risk of other
serious vision conditions, such as cataracts and glaucoma.
Foot damage. Nerve damage in the feet or poor blood flow to the feet increases the risk
of various foot complications. Left untreated, cuts and blisters can become serious
infections that may ultimately require toe, foot or leg amputation.
Skin and mouth conditions. Diabetes may leave you more susceptible to infections of
the skin and mouth, including bacterial and fungal infections. Gum disease and dry
mouth also are more likely.
Pregnancy complications. High blood sugar levels can be dangerous for both the
mother and the baby. The risk of miscarriage, stillbirth and birth defects increases when
diabetes isn’t well-controlled. For the mother, diabetes increases the risk of diabetic
ketoacidosis, diabetic eye problems (retinopathy), pregnancy-induced high blood
pressure and preeclampsia.

Laboratory Needed
Plasma glucose
Patients with type 1 diabetes mellitus (DM) typically present with symptoms of
uncontrolled hyperglycemia (eg, polyuria, polydipsia, polyphagia). In such cases, the
diagnosis of DM can be confirmed with a random (nonfasting) plasma glucose
concentration of 200 mg/dL or a fasting plasma glucose concentration of 126 mg/dL
(6.99 mmol/L) or higher. [2, 80]
A fingerstick glucose test is appropriate in the emergency department (ED) for virtually
all patients with diabetes. All fingerstick capillary glucose levels must be confirmed in
serum or plasma to make the diagnosis.

Treatment and Prevention

Treatment of type 1 diabetes requires daily insulin injections. The injected insulin makes
up for the insulin that is not produced by the body. Most people with type 1 diabetes
need two to four injections per day.
People with type 1 diabetes must properly regulate both their dietary intake and their
dose of insulin. If a person takes too much insulin relative to their dietary intake, or if
they forget to eat, they can develop dangerous ypoglycaemia. If they take too little
insulin, or eat too much, they can develop ketoacidosis.
In order to properly regulate their insulin intake, people with type 1 diabetes need to
monitor their blood sugar levels several times per day. They do this by testing a sample
of blood. They must prick their finger and place a small drop of blood on a test strip. The
test strip is inserted into a device called a glucose monitor. An accurate reading of blood
sugar levels is returned within seconds.
Newer glucose monitors have test strips that take the blood directly from the spot that
was pricked. This process requires less blood. Other monitors allow blood to be taken
from the forearm, thigh or the fleshy part of the hand. This can be less painful.
Some people use a syringe for injections. Other patients use semiautomatic injector
pens that help to measure precise amounts of insulin.
An increasing number of patients use insulin pumps. Insulin pumps deliver a regulated
dose of insulin through a needle implanted under the skin. The insulin pump is worn in a
pack on the body. Some pumps include a sensor that constantly measures the level of
blood sugar, and adjusts the dose of insulin accordingly. Whether devices with such
sensors lead to improved health is not yet certain.
Fast-acting insulin may be taken as needed, depending on the amount of carbohydrates
ingested. Your doctor or dietitian will help you determine the best insulin and diet
schedule for you or your child.
A healthy diet and regular exercise are important for everyone—but particularly for
people with diabetes. A healthy diet for someone with type 1 diabetes not only keeps
the amount of glucose in the blood relatively constant. It also includes eating “good
carbs” instead of “bad carbs”, “good fats” instead of “bad fats”.
In order to keep blood sugar levels at a normal and relatively constant level, a person
with type 1 diabetes typically is advised to eat, exercise and take insulin at about the
same times every day. Regular habits help to keep glucose levels within the normal
range.
People with type 1 diabetes should get regular exercise. Exercise protects the health of
the heart and blood vessels in people with diabetes, as in everyone. In addition, regular
exercise helps to control blood sugar by causing muscles to use glucose and by
keeping body weight down. Ask your doctor how much and when to exercise to best
control your diabetes.
There is no proven way to prevent type 1 diabetes. Vitamin D deficiency, which is very
common, may increase the risk of diabetes. However, correcting the deficiency has not
been yet shown to prevent diabetes. Likewise, avoiding cow’s milk during infancy may
possibly prevent type 1 diabetes in genetically susceptible infants. But there is no
definite proof that this prevents the disease.

Ulcerative colitis
Ulcerative colitis (UL-sur-uh-tiv koe-LIE-tis) is an inflammatory bowel disease (IBD) that
causes long-lasting inflammation and ulcers (sores) in your digestive tract. Ulcerative
colitis affects the innermost lining of your large intestine (colon) and rectum. Symptoms
usually develop over time, rather than suddenly.
Ulcerative colitis can be debilitating and can sometimes lead to life-threatening
complications. While it has no known cure, treatment can greatly reduce signs and
symptoms of the disease and even bring about long-term remission.

Manifestation
Ulcerative colitis symptoms can vary, depending on the severity of inflammation and
where it occurs. Signs and symptoms may include:
Diarrhea, often with blood or pus
Abdominal pain and cramping
Rectal pain
Rectal bleeding — passing small amount of blood with stool
Urgency to defecate
Inability to defecate despite urgency
Weight loss
Fatigue
Fever
In children, failure to grow
Most people with ulcerative colitis have mild to moderate symptoms. The course of
ulcerative colitis may vary, with some people having long periods of remission.
Types
Doctors often classify ulcerative colitis according to its location. Types of ulcerative
colitis include:
Ulcerative proctitis. Inflammation is confined to the area closest to the anus (rectum),
and rectal bleeding may be the only sign of the disease. This form of ulcerative colitis
tends to be the mildest.
Proctosigmoiditis. Inflammation involves the rectum and sigmoid colon (lower end of the
colon). Signs and symptoms include bloody diarrhea, abdominal cramps and pain, and
an inability to move the bowels in spite of the urge to do so (tenesmus).
Left-sided colitis. Inflammation extends from the rectum up through the sigmoid and
descending colon. Signs and symptoms include bloody diarrhea, abdominal cramping
and pain on the left side, and unintended weight loss.
Pancolitis. Pancolitis often affects the entire colon and causes bouts of bloody diarrhea
that may be severe, abdominal cramps and pain, fatigue, and significant weight loss.
Acute severe ulcerative colitis. This rare form of colitis affects the entire colon and
causes severe pain, profuse diarrhea, bleeding, fever and inability to eat.

Laboratory Needed
 X-RAYS
 COMPUTERIZED TOMOGRAPHY (CT)
 LEUKOCYTE SCINTIGRAPHY (WHITE BLOOD CELL SCAN)
 ENDOSCOPY
 ENDOSCOPIC ULTRASOUND (EUS)
 ROUTINE BLOOD TESTS
 ANTIBODY BLOOD TESTS (BIOMARKERS)

Treatment and Prevention

If you are diagnosed with ulcerative colitis, your Aurora care team will work with you to
find the best treatment options. This may include medications, including:
Anti-inflammatory drugs
Immune system suppressor drugs
Antibiotics
Anti-diarrheal drugs
Pain relieving drugs
Iron supplements