Here is My Question:
Is there information on the long-term impact of B cell depletion therapies (whether treating MS or otherwise)? Specifically when the B cells are left to repopulate, do they become more inflammatory than before? What would be the rationale for these therapies if your disease could potentially be worse than before?

Answer:
This is an excellent question. First, we do not know of any rebound in disease activity as B cells repopulate. This suggests it is highly unlikely that the B cells that return are in some way more aggressive or harmful to you. In fact, there is no clear temporal relationship between the return of total B cells (so-called CD19 + cells) and the return of disease activity. People can go for long intervals after repletion of B cells without any return of disease activity. We can only say that a return of disease activity is more likely the longer the duration between infusions. There is evidence in other inflammatory conditions treated with anti-CD20 therapies (Ocrevus, Rituximab, Kesimpta and Briumvi are all anti-CD20 agents) that a return of disease activity is more likely once central memory B cells return. Whether this applies to Multiple Sclerosis is unclear at this time. Central memory B cells are a subset of total B cells that take longer to return than naive CD19+ B cells.

We also know that immunosuppression and secondary hypogammaglobulinemia are more likely with cumulative high doses of intravenous anti-CD20 therapies (particularly rituximab and Ocrevus; Briumvi is rather new with no experience to guide us at present). So far it appears that secondary hypogammaglobulinemia (one cause of immunosuppression and infections) is less common with low dose subcutaneous treatment using Kesimpta.

Answering your question directly requires us to gain a better understanding of the mechanism(s) of short and long-term benefit with anti-CD20 therapies. For instance, once we deplete your B cell population with these therapies, are the cells which return during the bone marrow repletion process less autoreactive and/or better regulated? If this were the case and we found a biomarker reflecting this improved regulation, we could personalize your treatment and avoid unnecessary prolonged B cell depletion and potential immunosuppression. Other individuals may require higher or more frequent doses for a desired benefit.

Hope this helps.

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
​#multiplesclerosis #Bcells #Bcelldepletion

Here is My Question:
Can you please explain what symptoms might be associated with a T9 spinal lesion? I currently have reduced sensation/numbness on one side (R) of my lower back, wrapping around my lower abdomen and down the front of my R leg. Some back and hip pain on R side as well. Thank you.

Answer:
You've done a great job describing the symptoms associated with a partial right sided demyelinating lesion at the T9 level. 

Sensory nerves carrying pain sensitive axons from the T9-T12 or even the L1 right sided dermatomes (depending on the length of the lesion in the cord) enter the spinal cord in this area and cross over to the opposite side of the spinal cord about 2 levels above their entry zone. These dermatomes (T9-L1) correspond to the region of numbness you describe on the right side of your trunk and the front of your right leg. From here they travel up the left side of the spinal cord in the spinothalamic tract.

Common symptoms include a tight squeezing sensation around the trunk, sensitivity to light touch or pressure and a burning or tingling sensation. Other possible symptoms really depend on the location of the region of demyelination and could include weakness in one leg, tingling in one or both feet, urinary urgency or retention, constipation, lack of sensation in your private parts or decreased balance.

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#multiplesclerosis #MS #partialrightsidedemyelinatinglesion

Here is My Question:
Can I get a permanent disability right after my diagnostic from SSI?

Answer:
SSI is based on age/disability and low income, whereas SSDI is based on disability and work history/credits. I suspect based on your question that you are looking for SSDI based on your disability level. This can be hard to qualify for shortly after a diagnosis of MS, since most individuals with MS do not have significant disability this early in the disease. Exceptions include people with primary progressive MS or very aggressive forms of MS. Even people with obvious disability are often rejected the first time they apply. It is often necessary to hire a lawyer to take your case before an administrative law judge in this circumstance to obtain SSDI. 

Talk to your neurologist or contact the national multiple sclerosis society for more information on applying for either SSI or SSDI.

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#disability #multiplesclerosis #MS #SSI

Here is My Question:
If I had a scan 6 months ago do I need another scan?

Answer:
There are many reasons for a repeat MRI scans 6 months after the last scan. I cannot comment further without knowing your case better. I would first suggest that you discuss this with the ordering provider, hopefully the doctor managing your MS.

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#MRI #multiplesclerosis #MS

Here is My Question:
Does MS cause tingling and burning sensations in different parts of the body?

Answer:
MS can cause various abnormal sensations, including tingling and burning, in any part of the body. Deciding whether an odd sensation is related to MS depends on a number of factors that a neurologist or MS specialist will elicit during their taking of your history and examination. These factors include the temporal onset and duration (episodic vs always present) of the symptom, location, precipitants, associated symptoms and findings, and the potential role of medication or other medical conditions.

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#MS #multiplesclerosis #tingling #burning

Here is My Question:
Hello, I was wondering why my neurologist only ordered a MRI of my brain and brain stem to establish new baseline post rituximab infusion? When I was first diagnosed I had lesions on both brain and spine. Just trying to get clarification. Thank you.

Answer:
There are several potential reasons that a neurologist would only order an MRI of the brain. These include but are not limited to the following:

1. Monitoring MRIs are done to assess for asymptomatic new or enlarging lesions. Over 80 % of the time this type of new lesion is found on a Brain MRI
2. It can be difficult to detect new lesions in the spinal cord when there are other lesions present. A process called Wallerian degeneration can even give the appearance of an enlarging lesion in the spinal cord when this is not the true.
3. MRIs are costly and often rejected by insurance companies if there is not a compelling rationale.

I suggest asking your neurologist directly since their reason might differ from those mentioned above.

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
#multiplesclerosis #MS #rituxumab

 Here is My Question:
My fingertips and feet are numb and if I eat anything cold my mouth feels like it’s burning. Is this MS?

Answer:
Very odd pattern of sensations for MS. You will need to be evaluated by a neurologist to figure out the cause of these symptoms.

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#multiplesclerosis #MS #numbness

Here is My Question:
Can you wear a fabric face mask in hospitals?

Answer:
Hospitals differ in their mask policies based on state, region and warning level. Some will ask you to put on the masks they provide at the door while others will allow you to wear your own cloth mask.

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#mask #covid #multiplesclerosis #MS