Causes of Unexpected Death in Patients With Multiple Sclerosis

Abstract

To determine the cause of death (as a result of neurologic or nonneurologic complications or accidents) in patients with multiple sclerosis (MS), we reviewed the autopsies of 50 subjects with MS from the Office of the Chief Medical Examiner of Maryland (OCME) between 1982 and 2004. The series included 32 females and 18 males (mean age, 45.8 years; range, 25-69 years) and the causes of death were classified into 3 categories: (A) neurologic complication directly related to MS; (B) nonneurologic complications or other medical causes; and (C) accidents, etc. Of the 50 cases, in 43 there was a history of MS, but in 7 subjects there was not, and the diagnosis was established by neuropathologic examination. In Group A, 21 (42%) cases, deaths were directly related to a neurologic complication; in Group B, 14 (28%) cases were related to the following nonneurologic and medical causes: ASCVD 9 (18%), metabolic disorder 1 (2%), pulmonary embolism 3 (6%), and bronchopneumonia 1 (2%); and in Group C, 15 (30%) cases, deaths were due to trauma, 9 (18%); intoxication, 5 (10%); and thermal injury, 1 (2%). Thus, among the 50 subjects, in 26, deaths occurred naturally; and in 24, from accidents, homicides, suicides, or undetermined causes. Pathologically, the majority of cases showed either chronic inactive (66.7%) or chronic active (15.6%) demyelinating lesions, mainly in the cerebral hemispheres. In some cases, it appears that demyelinating lesions, involving brain regions that regulate cardiorespiratory activity, could be considered as the immediate cause of death, but a large proportion appears to be due to other causes such as accidents and trauma. Thus, it seems likely that taking specific precautions could prevent some deaths in MS.

Effect of comorbidity on mortality in multiple sclerosis

“… 4 Deaths due to infection and respiratory disease were higher than expected, similar to reports in the United States. 8 MS-related mortality in our population was lower than that reported in prior studies in which 47% to 75% of patients with MS died secondary to disease complications, 38 , 39 such as urinary tract infections, pressure ulcers, and pneumonia. 40 …”

Sudden adult death

“…Fatal sagittal sinus thrombosis is usually considered in the context of pregnancy and childbirth [341,342], but it may occur in association with other conditions [343][344][345]. Sudden death has been described in patents with multiple sclerosis, either in association with heat [346,347], or in the context of brainstem or other vital area involvement [348]. Occasionally, the first presentation of a central nervous system tumor [349][350][351][352], including colloid cyst of the third ventricle, can be sudden death [353].…”

Problematic clinical features of powered wheelchair users with severely disabling multiple sclerosis

“…In our study, these cases resulted in referral onwards to the primary care team for further medical management. Although evidence is lacking to support the difficult clinical decisions needed to inform best rehabilitation practice for those with multiple health conditions [33], it is recommended that taking specific precautions could prevent some deaths in MS [32].…”

“…Comorbidities, e.g. thromboembolism may be causes of unexpected deaths [32] but which are amenable to prevention through adequate medical intervention. In our study, these cases resulted in referral onwards to the primary care team for further medical management.…”

“…While prevention and treatment of pressure sores is stressed in guidelines for MS management [34], these guidelines do not refer to the risks of osteoporosis (although these risks have been recognised for some time) [35], VTE [18,32,36] or coronary heart disease [32]. It is likely that the five users reporting fractures had undiagnosed osteoporosis.…”