John R. Rinker II, MD University of Alabama at Birmingham Birmingham VA Medical Center August 28, 2012
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2 John R. Rinker II, MD University of Alabama at Birmingham Birmingham VA Medical Center August 28, 2012
3 This continuing education activity is managed and accredited by Professional Education Service Group. The information presented in this activity represents the opinion of the faculty. Neither PESG, nor any accrediting organization endorses any commercial products displayed or mentioned in conjunction with this activity. Commercial Support was not received for this activity.
4 John Rinker, MD Grants/research support: Biogen Idec: Site PI for clinical trial; Investigator-initiated study Consultant/advisory board member: N/A Speaker s Bureau: N/A Honoraria from Industry: N/A CME Staff Disclosures Professional Education Services Group staff have no financial interest or relationships to disclose
5 At the conclusion of this activity, the participant will be able to: 1. Review the military service experiences of two Gulf War-era veterans with MS 2. Summarize the possible MS risk factors experienced by these veterans 3. Discuss the difficulty of linking MS onset with individual exposure
6 56 y/o white male, born : Enlisted in the Army at age 18. Served until No combat exposure. 1980: Re-enlisted into the Navy, where he served until medically discharged in 1998
7 : Stationed at Camp Lejeune, NC. Exposed to well water contaminated with perchloroethylene (PCE) and trichloroethylene (TCE) : On-board helicopter involved in the invasion of Grenada 1 VA has attributed at least 2 cases of cancer to this exposure
8 : Desert Shield/Desert Storm, Kuwait and Iraq. Hospital Corpsman/ Research Technician. Oil-well fires Collected soil and air samples collected to analyze for contaminants which indicated chemical & biological weapons
9 1982 (at Camp Lejeune): Hand paresthesias for several weeks without functional impairment. Resolved back to baseline. 1993, 94: Vertigo/dysequilibrium. MRI abnormal. 1996: Balance disturbance 1998: Optic neuritis, improved following IVSM followed by plasma exchange.
10 Medical: PTSD Social: Smokes cigarettes Family: No history of MS or autoimmunity
11 1998 MRI showed worsening lesion burden compared to 1994 Lumbar puncture abnormal Evoked potentials confirmed optic nerve conduction delay Vitamin B12 normal, MS mimics ruled out MS diagnosed May 1998
12 Sep 1998: Started SQ interferon beta-1b Using crutches intermittently for gait instability Symptoms gradually worsening through to present 2001: Switched to glatiramer acetate due to side effects on interferon 2000 s: Neurogenic bladder, worsening gait, occasional falls 2012: EDSS 6.5
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15 43 y/o African-American female, born 1968 National Guard member, employed by Alabama Dept. of Corrections Called to active duty April 2003 Deployed to Afghanistan July 2003 for 8 month tour of duty
16 Pre-deployment: Vaccinations against small pox, anthrax; anti-malarial pills July 2003-March 2004: Assigned to provide armed support for Explosive Ordinance Disposal team 2005: Deployed to Gulf of Mexico in aftermath of Ivan and Katrina
17 Mid-2004: New onset severe headaches shortly after end of duty tour 2007: Recurring urinary urgency/ incontinence; diagnosed with fibromyalgia, treated with SSRIs 2011: Ascending numbness from feet to chest and hands over 3 days; mild to moderate functional impairment at peak
18 Medical: PTSD; Migraines Social: Cigarette use, ½ to 1 ppd; rare alcohol, no illicit drugs Family: No history of MS or autoimmunity
19 Visual acuity normal, no red desaturation Cranial nerves normal Motor: R hand 4-/5, L hand 5/5; R psoas 4/5, L psoas 4+/5; other muscle groups normal Sensory: Absent sharp-dull discrimination in feet Reflexes: RUE>LUE; LLE>RLE No tremor, ataxia. Gait steady.
20 CSF: WBC 4, RBC 0 Protein 32 Glucose 61 IgG index 0.7 (ULN 0.66) + OCBs CSF ACE normal Normal lab work: ANA B12 CRP Lyme Ab Anti-SSA & B Ab RPR HIV ACE level
21 April 2009 April 2011
22 Started SQ Interferon beta-1a mid-2011 No relapse activity since starting interferon Follow-up MRI late 2011: Stable lesion burden May 2012: EDSS 1.5
23 SUBJECT 1 SUBJECT 2 Organic solvents Oil well fires Air/soil samples contaminated by chemical/ biological weapons? Cigarette smoke PTSD Pre-deployment vaccinations Theater of combat Cigarette smoke PTSD Katrina/Ivan aftermath
24 If you would like to receive continuing education credit for this activity, please visit:
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