Transverse Myelitis (TM) with possible Remote Multiple Sclerosis (MS) versus Recurring Transverse Myelitis (RTM) .
Areej Abu Hanieh
1130234 Birzeit Univers ity - palestine
*Demographic information : *Name : AA
*City : Anata
*Age : 15 years
*Gender : female
*Weight : 68 kg with a moon face.
*Height : 157 cm
*BMI for Children : 27.59
*Occupation: no - work
*Living arrangement: family
*Health insurance: health insurance .
*Reason for visit: for educational purpose .
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**Motion sickness , using mottilium (domperidone ), before 10 years.
*Before 2 years she was diagnosied with Acute flaccid paralysis , M/P
Guillian bare syndrome , CNS Lupus , Seizure disorder , Renal
impairment , DVT , Multiple sclerosis , transverse myelitis , in the
beginning of the treatment , was used , mottilium (domperidone ) ,
Ratidine (Ranitidine) ,Scobutyl (Hyoscine-N_Butyl Bromide) 10 mg ,
metocloropromide , for 4 days , without any improvement ,then she kept
alive by nasogastric and setup mechanical ventilator .
*Tracheostomy operation .
*Then they set up her on Lasix (Feurosemide) , Nifidepine for
hypertension .
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*Rocephin (ceftriaxone) , Vancomycin , at meningitis dose
Acyclovir (zovirx). For the possibility of
meningioencephalopathy . while vancomycin and acyclovir where
stopped due to acute renal failure .
*Ceftriaxone , cloxacilin for 14 days , azithromycin for 3 days for
the possibility chest infection .
*Flucanozle adjusted to renal failure for yeast in urine .
*Phenytoin , Depalept (Valproic acid) for convulsions .
*Heparin , then shifted to Clexan (enoxaparin) , then shifted to
Coumadin (Warfarin) for DVT .
*Solu-medrol (methylprednisone) , cyclophosphamide monthly for
the possibility of the CNS – Lupus .
*Rituximab , that cause anaphylactic shock .
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*Discharg medicines : *Prednitab (Prednisolone 20mg) 1x1 .
*Imuran (Azathioprine 50 mg) , 1 tablet in a day
*Cellcept (Mycohphenolic Acid 360mg) , 4 tablets in a day
*Coumadin (warfarin 1mg) ,1 tablet in a day .
*Calcium 600mg
*Alpha-D3 0.25mg
*Depalept (valproic acid 200mg)
*Omeprazole 20mg , one tablet in a day
*Osteotab (alendronate sodium 70mg)
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*
*Patient behavior , Expectation from her
medications:
*Patient take medication because she believe that this
medecines is her choice to get better and be able to live
normal life again , and live like a normal girl , although she
take every day 8 tablets of different medications , but she got
stamina , her parents encourage here and help her take her
medications , to end the regiment , she suffer from
myoclonic that it is very painful for her , so she said , that
taking 8 tablets in a day is better and less painful than single
seizure for a couple of seconds, and she hope that she will
get better soon if she adhere the complete regiment as doctor
told her .
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*Social drugs : one tea cup in a day
.
*Vaccination history : Childhood
vaccination , No recent vaccines .
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*
Drug Indication Date dosage Reponse
and Safety Myfortic (Mycophenolate
Sodium) 360mg
Multiple Sclerosis vs
tranverse myelitis
Before 6 months One Tab daily Good
Depalept (Sodium
Valproate)200mg
Myoclonic seizures Before 6 months Three tablets
daily
Good
Prednitab (Prednisolone)
20mg
Multiple Sclerosis vs
tranverse myelitis
Before 6 month
(tapering
regimen)
One tab daily Has serious side
effect
Calcimore (Calcium
Carbonate) 600mg
Calcium deffiency
Prevent osteoporosis
Before 6 months 2 Tab daily Good
Alfacal
(alfacalcidol)0.25mcg
Vitamin D deffiency Before 6 months One Tab daily Good
Coumadin (warfarin) 2mg DVT Before 2 years One Tab daily Has side effect
as bleeding
Omega – 3 supplements Before one
month
Day after another
Fenugreek , parsley UTI Before 2 weeks PRN Good
IVIG (IgG) Immunedeffiency Before 6 months 25 gr/day every 2
months
Good
Trufen (Ibuprofen) 200 mg Pain PRN (2 Tablets in
a day)
Good , affect on
warfarin
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**ENT : blurred vision .
*GI : She has a stomach pain and burning in stomach (upper pyloric sphincter , Gastric ulcer) that increase with food taken.
*Heme : she has a high ESR (erythrocyte sedimentation rate) range , low RBC (red blood cells) , high MCH (mean corpuscular hemoglobin) , Low PLTS counting .
*GU : UTI (Urinary tract infection).
*Neurological : numbness .
*Muscoskeletal : legs pain due to obesity and DVT and edema , pain and defect in the cartilage in the femur – hip joint (Avascular necrosis ,Bone necrosis) for the right leg .general weakness in skeletal muscles , the pain scale 7 -8 .
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Test Results Normal range
ESR 28 <20
WBC 4.3 5-10 x10^3/micro L
RBC 4.4 4.2 – 5.4 x10^6 micro L
Hb 13.4 12-16 g/dl
Hct 39 38-47 %
MCV 88 82-92 micro m^3
MCH 31 27-31 pg/ml
MCHC 35 32-36 %
PLTS 200 150 – 450 x10^3/microL
ALT (GPT) 5 4 – 36 U/L
Creatinine ,serium 0.7 0.6-1.2 mg/dL
INR 3.7 <1.1 for normal people
, warfarin use patient
2.0 – 3.0
Pt 41 11-14 seconds
Ptt 30 25 – 35 seconds
LAB Tests 11/10/2016
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**Adverse effect of prednisolone , weight gain due to increase the
apetite , blurred vision ,peripheral edema ,irritability with
depression , numbness , facial hair growth , round face , moon face
(is high fat in the face due to long exposure for the corticosteroids),
menistrual irregularities , sweating , thining of the scalp hair, defect
in the cartilage in the femur – hip joint for the right leg. (bone
necrosis in right leg) , hoarseness .
*Drug – Drug Interactions (warfarin with ibuprofen ) , high INR
level , that she is in a real risk of bleeding while taking warfarin .
*adverse drug reaction , Bone pain with mycophenolate sodium.
* need additional drug therapy , the blurred vision and frequent
urination, headach and fatigue due to hyperglycemia .
*Additional drug therapy : need medication for UTI .
*Additional drug therapy : for Gastric Ulcer . 13 MS vs TV - Areej 05-Feb-17
*Drug –drug interaction between warfarin and
Ibuprofen :
Goal of therapy :
Has an INR between 2.0 -3.0.
- Ibuprofen should be stopped and replace it with
paracetamol at the minimum possible dose to avoid
bleeding , the dose per day should not exceed 1g (2
tablets in a day), or oxycodone in severe pain cases.
- Decrease weekly dosage by 10% or by 1 mg/d for 3 days of
next week (3 mg total); repeat PT in 1 week.
- The new regimen will be (Total dose = 11 mg) :
Day 1 2 3 4 5 6 7
Dose (mg) 2 1 2 1 2 1 2
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*Risk of Hyperglycemia :
*The frequent urination , blurred vision , headache , and
fatigue , due to hyperglycemia due to prednisolone side
effect , better to do blood sugar tests , HBA1C and
Fasting blood sugar (FBS) .
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*Decrease bone necrosis development:
- Pharmacological Treatment : Take medication to decrease
the pain like paracetamol , or using topical painkillers , such
as Diclofenac sodium topical (Rufenal 1%) , or Ibuprofen
topical (Isofen 1%)
- or use oxycodone in severe pain .
- Non Pharmacological Treatments : Reducing the weight and
stress on her affected bone can slow the damage. she might
need to restrict her physical activity or use crutches to keep
weight off her joint for several months.
Exercises. she may be referred to a physical therapist to
learn exercises to help maintain or improve the range of
motion in her joint.
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*Decrease the weight :
- Non pharmacological intervention :
Decrease the amount of food she take , decrease the simple
sugar and fat taken , increase the numbers of meals in a day
, replace artificial snacks that has a lot of calories with
fruits and vegetables , replace the white bread with black
bread and high fibers , decrease the sugar in milk cup, do
exercises that suitable for her , like walking , swimming .
*Improve the vision for better life :
- I advise her to go to the doctor (Ophtalmogical
examination) and do an eye test ,wear glasses if it is
needed, to decrease eye blur development .have an
optimum reading distance when reading from books and
labtops , and better to follow , 20 ,20 ,20 rule, to decrease
eye stress , protect her eye from the sun .
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*Decrease the edema in lower extremitis :
*1. Bed rest
*Decrease peripheral pooling (by raise the legs above body level).
*Augment blood volume in central circulation
*Increases sodium diuresis (Furosemide , Thiazide)
*2. Sodium restriction
*1-1.5 mEq/kg/day
*Avoid salty foods
*3. Water balance
*Daily intake = Urinary loss + Insensible water loss
*When diuresis occurs, avoid water restriction
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*Diuretic therapy:
*1. Spironolactone 25mg
*The dose for people with edema and hypokalemia is (25-200 mg
daily)
*1 to 3 mg/kg/day P.O.
*Give her 100 mg daily (4 tablets daily) .
This treatment for Edema and hypokalemia .
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*Gastric ulcer :
- Non pharmacological treatment :
Avoid these foods :
*Whole milk and chocolate milk
*Hot cocoa and cola
*Any beverage with caffeine
*Peppermint and spearmint tea
*Green and black tea, with or without caffeine
*Orange and grapefruit juices
*Spices and seasonings:
*Black and red pepper
*Chili powder
*Mustard seed and nutmeg
And she do not eat before bedtime , in addition better for here to eat small amount.
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*Non pharmacological treatment :
- Given Ranitidine 150mg twice daily .
- 4 to 10 mg/kg/day administered in 2 divided doses,
every 12 hours.
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*Sweating :
- Use over the counter persiperant combined with
deodorant , help control the sweating odor.
*The treatment of UTI : is trimethoprim/sulfamethoxazole , Alternative
antibiotics include amoxicillin/clavulanic acid .
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*Menestrual Irrigularity (Amenorrhea):
1 - Non Pharmacological treatment :
- She should eat a properly balanced diet.
- She should restrict the amount of fat in their diet
- A moderate exercise program may restore normal menstruation.
- restore and maintain a healthy body weight.
- finding ways to deal with stress and conflicts may help.
2-Pharmacological treatment:
- Dydrogesterone (Duphaston, Abbott)
Duphaston 10 mg b.d. from day 11 to 25 to produce an optimum
secretory transformation of an endometrium that has been
adequately primed with either endogenous or exogenous estrogen.
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**Monitor the INR by doing test after 7-14 days .
*Monitor the prednisolone dose every week for tapering regimen if it needed .
*Do an X-Ray image for the right hip to follow up the Avascular necrosis and prevent its exacarbation monthly.
*Monitor the vital sign and lab tests for MS medications especially corticosteroids and mycophenolate every 1 month.
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Disease-Modifying Therapies
Nine disease-modifying therapies (DMT) have been approved for
treatment of relapsing-remitting multiple sclerosis (MS) in the adult
population, including 6 first-line therapies (glatiramer acetate [GA],
intramuscular [IM] and subcutaneous [SC] interferon [IFN] beta-1a,
and SC interferon-beta-1b, fingolimod, and teriflunomide) and 2
second-line therapies (mitoxantrone and natalizumab). In addition,
therapies such as rituximab, daclizumab, and cyclophosphamide
have been evaluated in phase II trials in adults with breakthrough
disease, as have add-on therapies such as monthly steroids and
intravenous immunoglobulin (IVIG).
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