Multiple Sclerosis with Limited Treatment Options: A Case Report on Azathioprine as an Alternative Therapy
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https://doi.org/10.19166/lijn.v2i2.11134关键词:
Multiple Sclerosis, Azathioprine, Demyelination, Oligoclonal Bands, Dawson's Fingers摘要
Introduction: Multiple sclerosis (MS) is a chronic immune-mediated disease affecting the central nervous system, characterized by demyelination and progressive disability. Estimated prevalence in Indonesia is approximately 0.01 per 100,000 population. Treatment includes managing acute relapses with corticosteroids and DMT to prevent relapses and further disability. Immunosuppressants such as azathioprine are often used in Indonesia as a more accessible and affordable alternative to standard DMTs.
Case Presentation: A 30-year-old woman presented to neurology outpatient with history of progressive bilateral lower limb weakness since 2019, accompanied by urinary dysfunction and numbness below abdominal region. Neurological examination revealed paraparesis of lower limbs, hyperreflexia, positive bilateral Babinski signs, hypoesthesia below T10. Brain MRI demonstrated demyelinating lesions in the corpus callosum, bilateral periventricular white matter, and subcortical frontal and parietal lobes, forming a Dawson’s finger pattern. Spinal MRI revealed a demyelinating lesion at the T11 level. Cerebrospinal fluid (CSF) analysis showed type 2 oligoclonal bands. The patient was diagnosed with multiple sclerosis and treated with intravenous methylprednisolone and azathioprine as maintenance.
Discussion: The clinical presentation, characteristic MRI findings, and positive oligoclonal bands supported the diagnosis of multiple sclerosis. Although azathioprine is not considered a first-line DMT, it remains a practical treatment option where access to approved therapies is limited.
Conclusions: This case highlights the importance of integrating clinical, radiological, and CSF findings in diagnosing multiple sclerosis. Treatment should be individualized according to the patient's clinical condition and available healthcare resources, while improving access to evidence-based DMTs remains an important goal.
Keywords: Multiple Sclerosis, Azathioprine, Demyelination, Oligoclonal Bands, Dawson’s Fingers
参考
1. Rae-Grant A, Day GS, Marrie RA, et al. Practice guideline recommendations summary: Disease-modifying therapies for adults with multiple sclerosis. Neurology. 2018;90(17):777–788. Available from: https://doi.org/10.1212/WNL.0000000000006722
2. Dighriri IM, Aldalbahi AA, Albeladi F, Tahiri AA, Kinani EM, Almohsen RA, et al. An overview of the history, pathophysiology, and pharmacological interventions of multiple sclerosis. Cureus. 2023 Jan 2. Available from: https://doi.org/10.7759/cureus.33242
3. Ghasemi N, Razavi S, Nikzad E. Multiple sclerosis: Pathogenesis, symptoms, diagnoses and cell-based therapy [Internet]. U.S. National Library of Medicine. 2017;19(1):1-10. Available from: https://doi.org/10.22074/cellj.2016.4867
4. Haki M, AL-Biati HA, Al-Tameemi ZS, Ali IS, Al-hussaniy HA. Review of Multiple Sclerosis: Epidemiology, Etiology, Pathophysiology, and treatment. Medicine. 2024 Feb 23;103(8). Available from: https://doi.org/10.1097/md.0000000000037297
5. Shi M, Liu Y, Gong Q, Xu X. Multiple sclerosis: An overview of epidemiology, risk factors, and serological biomarkers. Acta Neurologica Scandinavica. 2024 Jan;2024(1). Available from: https://doi.org/10.1155/2024/7372789
6. Montalban X, Gold R, Thompson AJ, et al. ECTRIMS/EAN guideline on the pharmacological treatment of people with multiple sclerosis. Mult Scler. 2018;24(2):96–120. Available from: https://doi.org/10.1177/1352458517751049
7. Ontaneda D, Thompson AJ, Fox RJ, Cohen JA. Progressive multiple sclerosis: prospects for disease therapy, repair, and restoration of function. Lancet. 2017;389(10076):1357–1366. Available from: https://doi.org/10.1016/s0140-6736(16)31320-4
8. Ghezzi A, et al. Azathioprine for multiple sclerosis: clinical efficacy and safety profile. Neurol Sci. 2019;40(Suppl 2):S161–S165. Available from: https://doi.org/10.1002/14651858.CD003982.pub2
9. Casetta I, Iuliano G, Filippini G. Azathioprine for multiple sclerosis. Cochrane Database Syst Rev. 2007;(4):CD003982. Available from: https://doi.org/10.1002/14651858.cd003982.pub2
10. Pandit L. Multiple sclerosis care in a low Middle-income setting in South West India. Int J MS Care. 2025. Available from: https://doi.org/10.7224/1537-2073.2024-082
11. Multiple Sclerosis International Federation. Atlas of MS 2020: Mapping multiple sclerosis around the world. London: MSIF; 2020. Available from: https://www.msif.org/resource/atlas-of-ms-2020/
