Questions and Answers from Education Summit - Part 2

At the Education Summit, we opened the floor for Q & A for participants to ask questions related to the doctors presentations. The Q & A was Miravallerecorded and we’ve made the information available online! 

Here is the latest round of questions answered by Dr. Augusto Miravalle, MS-specialized neurologist at the Rocky Mountain MS Center Clinic at Anschutz Medical Campus:

Would having had mononucleosis have an effect on the chances of getting MS?

Yes, there is evidence to suggest that having mononucleosis (mono) would impact the chances of getting MS. A large study looking at patients who were exposed to mono or Epstein Barr Virus, particularly later in life, showed that those individuals had a higher incidence of MS.  

If you are exposed to EBV early on in life, like 95% of the population is, you have apparently a lower risk of developing MS. For those who are exposed later on in life, they have higher chance of a dysfunctional or an abnormal immune response – so it’s a matter or whether you’re exposed and also when the exposure occurs.

You mentioned that interferon drugs were less effective for some types of patients. What types of patients are those?

Unfortunately, we do not have good predictors or biomarkers that will tell us how someone is going to respond to most drugs, in this case interferons. It does seem that there are some people that don’t have an optimal response to interferons. Because we can’t predict this ahead of time, it’s important for people receiving any therapy, to have a plan with your doctor about how to monitor your progress, for example by using regular MRIs to identify a poor response to treatment.

What can be done to increase the size of MS patient samples to increase data for valid results?

Participation is key to moving research forward - the more people that participate in research studies, the more valuable information that can be obtained in the research. That’s why we need patients to be part of the Rocky Mountain MS Center database. And we need patients to sign up for My Health Connection at the University Hospital. It’s also important for patients to participate in educational seminars so we can capture patients and healthy controls for clinical studies. CLICK HERE for more information about MS research.  Learn more about clinical trials that are currently recruiting participants in the clinicial trial section of this eMS news edition.

MS is an inflammatory disease. What does the research pipeline look like for other inflammatory diseases like rheumatoid arthritis? Do you collaborate with other inflammatory disease researchers?

Other inflammatory diseases that are similar to MS are often mistaken for MS – diseases such as Neuromyelitis optica (NMO), rheumatoid arthritis and lupus. We have a biobank that we share with other researchers studying inflammatory diseases. The biobank is a biorepository of spinal fluid and blood samples. The data is available for researchers to collaborate in large scale studies. We are also currently working on NMO research and we are part of a large database called Accelerated Cure Project (ACP) that is also looking at multiple centers and disorders that are related to MS but that are different from MS. You can learn more about this collaboration by visiting

Have vitamin B12 levels been shown to be a factor in MS therapy?

No. There is a type of immune mediated vitamin B 12 deficiency that may be associated with autoimmune diseases, like MS. However, vitamin B12 supplementation will not affect the course of MS. In some patients who already have Vitamin B deficiency and have neuropathic pain or neuropathy, Vitamin B supplements might improve their symptoms, but it will not have any impact on the course of the disease.

Is there any defined association between B cell activity in MS patients vs. B cell lymphomas?

Not that I’m aware of.

Why did I develop MS in old age?

It’s difficult to say. We do see that patients with MS tend to manifest clinically earlier in life, but the spectrum of diagnosis ranges anywhere from children to elderly.  We have patients as old as 70 years old being diagnosed with MS. We’re not sure why that happens; it probably has something to do with early compensations by the brain – due to higher brain reserve - that might mask onset of MS in earlier years.

What are the chances that my sibling may have MS?

As we discussed, first degree relatives of patients with MS have a higher chance of developing MS. A first degree relative is a parent or sibling. In Colorado, that chance is thought to be approximately 3%; whereas someone without a first degree relative with MS has approximately a 0.7% risk. So it’s a higher chance, but it is still a multi-factorial risk. Clearly genes play a role in the development of MS, but current estimates are that they contribute less than 20 percent to your risk, so they don’t tell the whole story. Meaning that not only genes have impact, but also environmental factors play a role.

The best recommendation to prevent MS will be lifestyle modifications that are proven to decrease risk of MS. For example: Vitamin D supplementation, avoidance of smoking and salt in diet. And early diagnosis is also important. At the first sign of any neurological symptom, the patient should check with a neurologist for the possibility of MS.

Should I allow my kids to be exposed to more viruses early on?

No. It might be true that early exposure to infections might prevent later autoimmune responses or dysfunctional autoimmune responses. However, we still need to prevent infections and viruses, particularly through vaccinations. Vaccinations are very important. We should continue to vaccinate our kids to prevent infections, as well as treat infections as soon as they are identified. We should not promote infections in order to prevent autoimmune disorders. 

Can herpes zoster (shingles) trigger MS?

It’s hard to tell. The answer is probably no. However, it is possible that when somebody has MS and develops reactivation of herpes, that may trigger a relapse. But the association between herpes zoster virus and MS has been weak.

Are researchers working on developing a vaccine for Epstein Bar Virus (EBV)? If so, what stage is research in?

There was a phase 2 clinical trial for a EBV vaccine; however, the study did not indicate that the vaccine was beneficial in preventing the EBV infection. (Results published in Vaccine magazine in 2013)

Canada is a notable exception on the Epstein Barr Virus (EBV) map for MS frequency. There is a low rate of EBV but high rate of MS. Can you comment on that apparent contradiction?

It is true.  EBV is just one factor that might contribute to MS, but it is not the cause of MS. There could be other factors.  Another way to explain is to look at migration patterns. It seems likely that the risk the virus may contribute to developing MS has to do with exposure to the virus early on in life. If people then migrate to a different places, that might change the incidence and prevalence of MS.

Why are there so many varieties and symptoms of MS across populations? What causes differences across populations in brain atrophy?

MS is a widespread disease in the central nervous system, meaning that it could have an impact anywhere in the central nervous system – could be the eyes, could be the cerebellum, could be the memory center, or the spinal cord. Depending where the lesions are, the symptoms are going to be different.

In terms of brain atrophy differences –that’s a great question. Perhaps environmental factors like smoking or lack of exercise might predispose you to faster rates of brain atrophy. People who have a higher brain reserve due to higher cognitive or physical activities early on in life may have a lower rate of brain atrophy.

Apparently we’re seeing increased rates of autoimmune diseases. If genetics influence autoimmune diseases and the genes are passed to the next generation , will we seeing a higher and higher risk of autoimmune disease?

Great question. The answer is possibly yes. We see that the rate of autoimmune disorders are generally increasing in the world, not just MS. And that increased incidence may have the genetic /environmental factors associations. Changes in lifestyle with less physical activity, more smoking and less sun exposure may increase the rate of autoimmune disorders in general. And of course the changing paradigm of infections may also play a role in that association.