Multiple Sclerosis Community
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147426 tn?1317269232

Infections and Relapse

This has been a rocky spring for me as I have mde you all painfully aware.  The latest in my adventures against the world, gravity and nasty, little microbes is my fever blister.  Yes, I am reduced to reporting every hang nail, hangover (I wish!) and hang-up I have.  I was just improving from my hand fractures, UTI and my mom's fall.  Things seemed to be evening out.  Then last weekend I found both legs stiff and spastic instead of just the right one.  This was new and really brought the image of walking like Frankenstein (or frankensteining, as we have called it here) to my family's mind.  "Why was I walking like that??"  The next day I was in the middle of a full-blown fever blister or outbreak of Herpes I.  I always react with fever, aches, headache and general yuckiness.  It reminded me to have a discussion on why we need to be aware of ALL of our infections when we have MS or are suspected of having MS.


As we all know there is a direct correlation between having an exacerbation of our disease and having our immune system stimulated.  What kinds of things stimulate the immune system?  First and foremost are infections - infections of every kind.  Others are things like immunizations and the post-partum period when the dulled immune system from pregnancy works it's way back up to normal functioning.

No one can do much about pregnancy nor the period after it, but we all can be aware of infections and their effect on us.  Some infections we can do something about; some we can't.  But, it is always a good idea to think about all possibilities when our disease suddenly appears to be worsening.  It is important to tell our docs about any suspicion we have of an infection even if we know we will get over it by ourselves.  The reason for this is that the longer the infection is active, the more the immune system is stimulated to take care of it.  You want to treat any treatable infection ASAP to shorten the duration of the stimulation of the immune system.

Viral infections:

The most common of these are colds and influenza.  We remain helpless before the common cold, but we can take steps to prevent them.  Basically this means good handwashing and common sense hygiene.  The flu is a pwerful stimulator of relapses.  Those of you who know me know that I am TOTALLY in favor of getting the flu vaccine as they become available each year.  Even though the vaccine might stimulate a relapse, it is typically not a severe one, whereas the actual infection can cause a real doosey.  

If one of us gets the flu, we should seek antiviral treatment for it ASAP - preferably within 24 hours of the beginning of the fever, muscle aches, sore throat and all that goes along with it. There are several meds that are proven to shorten the severity and length of the flu if taken early enough in the illness.   Most people don't know that the influenza virus is active and present all year long.  So, it is possible to get the flu at any time.  I certainly have seen it in every month of the year.  However, in the northern hemisphere it causes most of its illness between September and April.  Scientists think that part of the reason that it remains so quiet during the late spring and summer months is the increased exposure to sunlight.  There is some good evidence that this is due to increased production of Vitamin D during times of greater exposure.  Vitamin D does support healthy immune activity (geez, I sound like a TV commercial).  

All of us should be taking higher levels of Vitamin D than those traditionally recommended.  Unless your neurologist recommends something else, you all should be taking 2,000 IU daily.  Not only will this bolster your immunity against certain viral infections, but it may be beneficial in the behavior of the MS.

Herpes Infections

Fever blisters/cold sores/Herpes I - These are common in some people, occasional in others and never in some.  If you get the telltale signs of the tenderness and then the group of tiny blisters that get bigger and bigger then merge into one giant blister you need to get into see your doc NOW!  These are easily treated with oral antiviral meds like acyclovir.  If started early enough (prefgerably the same day they appear) a ten-day ordeal can be over in 5 days and the immune system can be protected from a week and a half of stimulation.

The same advice is true gor genital Herpes II.  Treat outbreaks orally and/or use chronic prophylactic antiviral meds if recommended by your doctor - both to prevent your own outbreaks and to prevent transmission to a partner (which can happen even if your are not in an outbreak).

There are other viral infections, but most of them aren't treatable.

BACTERIAL Infections

Urinary Infections:  Over and over we here on the forum tell people to be checked for hidden infections when their symptoms worsen.  Far and away the most common hidden infection is a UTI.  It is VERY common for people with MS to have difficulties emptying their bladders completely.  Urine that stays in the bladder without being voided is a set up for bacterial infections.  These are almost always bacteria from the intestines.  This is true for men and women BOTH!  A uti can worsen spasticity, cause all a person's symptoms to worsen and even cause a true relapse.

Don't fool youself into thinking you ALWAYS would know if you have an infection.  Because of the reduction in sensation and proper signals many of us have we may not get the burning, cramping, frequent urination typical of urine infections.  Many of the members will tell you that they have had unsuspected UTIs as the cause of their worsening symptoms.  It is routine now for docs to hold off using antibiotics until a culture comes back showing a definite infection.  People with MS, however, should be treated until the culture comes back showing they are not infected.  The reason for this is simple.  The culture takes two or three days.  We don't want to lose those few days to a building relapse.  Sometimes we need to educate our doctors on this.  I had to tell an Urgent Care doc about this recently.  

I am in total agreement with the growing philosophy to withhold antibiotics until they are clearly indicated - BUT ONLY in all the OTHER people in the world; not in MS.  We have too much to loose - literally.  


31 Responses
147426 tn?1317269232
Bacterial Infections (con't)

Ear Infections:   While more and more docs are waiting to see of ear infections will resolve by themselves, if there are signs that the ear might have a bacterial infection this should be treated, especially if MS symptoms are worsening.

External ear infections:  These are infections in the external ear canal (like Swimmer's Ear).  These do not usually cause the body to respond with increased immune activity and they are usually treated just locally.

Sinus Infections:  These are a deep-seated infection that requires higher doses of antibiotic and longer duration of treament.  If there is any question about whether it is just sinus pressure or a true infection then the question should be answered by a CT scan of the sinuses without contrast.  This will tell immediately.  If the CT is going to be delayed, then treatment with antibiotics should begin.

Strep throat - It goes without saying that strep should be treated.  Primary care docs should be able to do quick tests for strep in the office.  However, the vast majority of sore throats are viral and not strep.  Chronic tonsilitis should be evaluated by an ENT to se if there is an infected core within the tonsil possibly a tonsilectomy is needed.

Skin Infections:  A lot of skin infections stay local.  The infection may be like a small boil or a tiny abcess that drains on its own.  But, if the skin's immune system isn't hold the infection in place (keeping it localized) then antibiotics are needed.  Don't sit at home with a hangnail which is now causing increasing pain and swelling of the finger, along with redness and heat.

Impetigo - Unless the scabby areas are getting swollen, red and hot, impetigo (strep skin) can usually be treated locally.

Conjunctivitis - "Pink Eye".  Typically this begins as a viral infection that clears by itself.  But, when it gets very think and goopy (actual medical term) it may need topical antibiotics.  This shouldn't cause stimulation of the immune system unless it begins to spread into the surround areas and then it is a VERY serious infection usually along with high fevers.

Bowel Infections:  Again, most cases of gastroenteritis are viral - like Rotavirus and other infectious diarrheas.  However, when accompanied by fever, mucousy or bloody diarrhea should be checked and cultured.  The decision to treat or not to treat is best made by the doctor.  Sometimes the use of antibiotics is a definite no-no.

Fungal Infections - Like yeast infections.  This is an area of great disagreement.  In general, yeast infections should be treated locally and with probiotics.  If they are out on the skin, generally topical treatment is enough.  These should not be suspected of causing a relapse.

Parasitic infection of the bowel - Many of these cause enormous stimulation of the immune system.  People with chronic bowel problems, cramping vomiting, diarrhea should be evaluated by a doc.  Make sure they check for parasites, especially if you travel, camp, or have family members who do.

Summary -
I got a little wordy here.  I just want to remind you that there are many infections beyond those we usually talk about.  If there is treatment for one, then we are better off to treat than to "tough it out".  

The flip side of this whole discussion is whether we should be bolstering our immune system with anything other than good hygiene, avoidance, and Vitamin D.  Many people misunderstand the effect of MS on our immune system or misunderstand that having MS means our immune system is weak.  In general, people with MS having completely normal immune systems except for that part that has to do with the effect of certain immune cells in our central nervous systems.  WE DO NOT HAVE WEAKENED IMMUNE SYSTEMS.  We do not need to take supplements to strengthen our immune activity.  In fact, many MS experts recommend against such supplements for the very reason that - theoretically - such supplements might increase the activity of our diseases.

Through the last 3 or 4 decades epidemiological data show that people with MS tend to have fewer colds.  Along the same lines there are currently a couple studies looking at the incidence of cancer in MSers, because of the historical sense that cancer is less common in those with MS.  I'll re-look up those studies and get back to you.

Quix - Founder and President of the Support Group for People who Talk Too Much - ON-AND-ON ANON
572651 tn?1531002957
Wow, girl.  When you come back, you come back full strength plus some.  This is excellent and I trust it will become another health page.

Unfortunately  I know first hand how my body doesn't properly signal me tht there is an infection brewing.  Even my instinct tends to fail me when it comes to spotting UTI's.

Thanks for the great recap.

hugs, L
739070 tn?1338607002
Great piece Quix! I agree, another Health Page. Glad you are slowly getting back to your norm. You and your family remain in my daily thoughts.

Sending warm wishes,
1382889 tn?1505074793
Incredibly helpful info, some I knew, much I didn't. Thank you so much for sharing when you are struggling so mightily.

I am printing it out and also forwarding on to a few family members who have asked for info on MS.

It is wonderful reading your posts as always. Keep getting better. You are always in our thoughts.

987762 tn?1331031553
I second the health page!

Interesting stuff and I totally agree about the confusion regarding our immune systems. Long before MS got on the radar, I had already been told by more than one dr over my life time, that my immune system was over active or over protective. That was mainly because i've had probelms with chilblains since i was a child, they got worse as I get older and seem to include just about all the knuckles in my entire body now lol My hands and toes seriously look like RA, all lumpy, painful and twisted but I dont have RA and they go back to normal with the change in weather, its just chilblains and my immune system makes it more of a problem than it should.

For probably a decade or more (lol times flies) i thought my immune system when it came to 'infections' was faulty or sluggish. Everyone else got over their bug within a couple of weeks and yet i always got worse and continued to get worse for months on end. Weird but i felt 'sicker' after the initial signs of the bug were gone and the antibiotics had done their job. It made sense to everyone that my immune system wasn't working properly and needed boosting.

Since MS entered my world i now see the problem as being that my immune system is working but it doesn't know when to stop attacking, so that life time of already knowing my immune system was over protective is right. My immune system maybe rightly going after the invader but once that sleeping dragon is awake, thats when the problem really begins. It doesnt matter what set it off, once its on the attack it just keeps on keeping on, somewhere along those years it started nibbling on my brain.

What i really do not get is WHAT stops it, why does it stop, what exactly happens to make my immune system start playing by the rules again. Something has to be happening to halt its attack, but what is it? I still have to wonder if that something is a 'real' invader redirecting my immune system towards it, its a very circular idea!


Avatar universal
Yay Qux!!

So glad to find you back posting, and you sure did it with a bang. Here's hoping your various troubles, from hang-nails on, will soon abate, and you find yourself having a happy and healthy summer.

Just one comment on infections. Recently, in quite a few threads I've noticed people warning about infections because they can cause pseudoexacerbations. But they can also cause real, and serious relapses that can be life-altering. So as Quix says, don't fool with infections!

1453990 tn?1329235026
My employer provides wipes for shared phones, desks, aircraft seats, tables, etc.  They found that it is less expensive to provide wipes to clean these "shared surfaces" than the lost productivity.  They also have lots of signage that reminds employees to wash hands frequently.  This includes after shaking hands with clients.

Thought you might be interested in how big companies view "Prevention vs. Cure."

667078 tn?1316004535
Quix you are the bomb! I always wondered what that expression meant. "The bomb" was the super decoding machine used to decode the German Enigma code in WWII.

You have the power to put information together in the best ways.

Godspeed on your recovery, glad you are back.

Avatar universal
Hi, Quix!  I'm a newbie here and I don't think we've been formally introduced but I have heard much about the infamous Quix and I have read your health pages several times over.  So much information available!

I love this article and I third (or whatever number we are on now) the idea that it should be a new health page.

Thanks for all you do!
Avatar universal
JJ, your post hit me right between the eyes!  OUCH!  ;)  I was reading along and saying "Yes!  Yes!"  You have described me to a tee with "Weird but i felt 'sicker' after the initial signs of the bug were gone and the antibiotics had done their job."  My husband has made the comment before several times "You never get sick but, boy, when you do, you really do!"

I'm still, of course, undx'ed but, man, this makes me think....

338416 tn?1420049302
Head on the nail, as usual!

I've had a couple of UTIs recently.  The first one didn't get noticed until my gall bladder problems, a few months ago.  So when I got the same kinds of buzzing shock sensations in my pelvic region, I got some cranberry juice - seems to have cleared it up.  I guess I'll just have to drink that on a regular basis.  But you're exactly right - aside from the buzzing, I would never have known.

Bob, whenever they have food here at work, I always end up catching something from contamination.  I should learn.
559187 tn?1330786456
Perfect timing!!  We have been having this discussion in my other MS group - those taking Gilenya.  

What do you think about those of us on immunosuppressive drugs like the interferons and now gilenya?  I had an infection recently and didn't even have a fever, just chills.  Same thing happened to SparkySarah.  With your knowledge of infectious diseases, are we in any particular danger or just the same as anyone not taking these drugs?

Thanks and good to see you posting.  

147426 tn?1317269232
Thanks for all your comments.

Julie - You bring up an important point.  I can't emphasize enough that the interferons and Copaxone are NOT at all immunosuppressive.  There is NO risk of increased regular infections and not at all of what is known as opportunistic infections (those infections which offer no risk except to suppressed immune systems).  The inerferon we take in higher doses is the same interferon that the immune system produces as a response to fighting infection.  (That's why we have fever, chills, aches and malaise as a response to influenza).

Now, the next level of drugs do suppress the immune system to varying degrees.  Tysabri inhibits infection fighting cells from moving into the brain.  This may be the way it combats the attacks of MS, but it also can rarely allow a brain infection to take hold without appropriate protection.  Gilenya also has some localized immune suppression in the CNS, but I have not seen anything that talks about the routine microbes that we encounter daily.

As to whether we responds to an infection with fever that is ineresting and I have no immediate answer.  Remember that fever, chills, headache, muscle aches and fatigue are the direct results of the immune system's production of interferon.  Not all infections cause fever.  Chills are aften a result of what is known as viremia or bacteremia.  This is when a germ gets loose in the blood in a wave.  Depending on the reason we are usually able to clear the invader, but if the seeding of the blood continues we can loose the battle and develop sepsis if the bug is a bacteria.  Lulu can tell you about that.

Also, chills often precede the fever and if you take the temp during the chills you may miss it.

I also wonder if those of us who were priorly on an interferon might have a blunted respnse to our own production of interferon during an infecton.  Remember, that the majority of people on an interferon see a reduction of the side effects after several months of use.  This might show up even after stopping the interferon.  We get an infection and might not get the fever and/or chills.  Just a thought out of my own head.

Take home lesson - People with MS do not have weakened immune systems, just ones that are off-kilter in a narrow area of the immune system's function.  The first line drugs to NOT suppress the immune system with regard to getting more regular infections.  Tysabri and Gilenya have slightly more suppression, but only in the CNS.  Other meds can be suppressive.

Other MS drugs like mitoxantrone are just like cancer chemotherapy drugs and DO suppress the immune system.

Also remember that if we are taking acetaminophen or any of the NSAIDS, even in fairly small amounts, it can suppress fever.

572651 tn?1531002957
sorry, totally off topic here.... just seeing your name pop up makes me smile.  It appears you are in full-force Dr. Q.  :-)    we have been missing you. a lot!

and yes, sepsis is not fun.  No major fever as a warning.  the wave as Quix calls it was quite the ride.  

147426 tn?1317269232
Bob - Great news about good hygiene in the workplace.  Now if ALL organizations would adopt it.

Cheesykins - If you are having worsened symptoms of the kind that took you to a neurologist, then yes, this can be exactly what a post-infection relapse looks like.

Jen - Studies on cranberry  show that the juice cannot clear an established UTI.  It might suppress the bacteria count for a while, but the UTI is likely to reappear.  There is some good data that large amount of cranberry is a fair suppressant of UTIs.  This means that if the urine is clear, the cranberry can kept future UTIs at bay.  Joever, for the juice to work you would need to drink enourmous amount of the juice (loke a gallon a day).  They have cranberry extract tablets (standardized to 500 units, I think).  These are strong enough to help.  I take them and have been able to stretch out the interval between my infections.  I always end up getting a new one when I have begun to forget the tablets and have let myself get dehydrated.

Cranberry works by keeping the bowel bacteria (gram negative) from attaching to to the bladder wall where they can reproduce.

Ess - the real relapse versus the pseudo-relapse comes up a lot.  If the MS symptoms go away immediately with the beginning of the antibiotics, then I guess you could call it a speudo-exasperation, but if the symptoms linger beyond that you would have to call it a real one, by the definiton of relapse.  I know some neuros use the terms differently and, in the end, I guess it doesn't matter.  If the symptoms last more than a day or two, I think they should be considered part of a real relapse.

JJ - If your symptoms following treatment of an infection are those of the MS then you are describing exactly why we are concerned about getting infections attended to quickly.  The sooner we can treat them (if treatment is available) then hopefully the less time the  MS has to get setttled into an attack.

As for making this an HP - why not?  I am going to trying to get some of the couple dozen topics I have started put up on the board this summer.

645800 tn?1466864555
This brought up a question of mine regarding immunosuppressants as I am on a strong one. (CellCept 2000MG daily ) Will this inhibit me from knowing when I get an infection or make me more susceptible to them?

338416 tn?1420049302
That's good to know!  So it might come on back - in fact, might be back and I just don't realize it.  I love cranberry juice, but I'm not sure I would be able to drink that much.  I'll have to stock up on the tablets!

Speaking of pseudo-relapses... My neurologist just recommended magnesium both for the PMS problems and my constipation.
1466984 tn?1310564208
Thanks for this and glad to see you!

I am a gray area patient - possible MS - but this past month have struggled with herpes (on the mouth) -which my doc gave me pills for - and UTI symptoms - but no UTI.

Doc mentioned urodynamics but said it could wait until  I see my gyn in Sept to mention it when he found out his office wouldn't do it (didn't want to step on my GYNs toes).....

I love the medical field.

Best to all.
Avatar universal
This is a very timely post for me. I recently, within the past two weeks, had a cold sore. One week later my eye was attacked by Iridocyclitis, Scleritis and Epislceritis all at once.

I am not diagnosed with MS or anything else but know that something is not right with me. Each of these things that attacked my eye are associated with autoimmune disorders of various sorts and the fact that I had all three hit me at once is a very strong indicator that there is a serious underlying systemic disorder going on. I just wish I knew what it was.
1437229 tn?1296073620
That is a great article.  I always look forward to your words of instruction.

I hope your life settles down soon.  I find it so crazy that I look forward to those times when my life takes a turn toward the mundane.  Right?

Thank you for being willing to share your knowledge with us.

1475492 tn?1332887767
Hi Quixotic1!

I'm curious, what about allergies? Would not treating your allergies cause a relapse or possible further progression of your MS? This post made me wonder since an allergic reaction is an increase in your heightened immune system responses.
1045086 tn?1332130022
This is a wonderful reference topic!  Please do convert it into a Health Page DQ.  I never manage to have my EASY button handy to find this stuff when I want to refer back to it.  It's better if I know I'll locate it in the smaller search area of the Health Pages.

One added suggestion for members with frequent (or surprise) UTI.  You might want to have a look at the www.labtestsonline.org site (one of Lulu's favs).  There are several different indicators that can suggest a bladder infection is brewing or full bore raging.  It's nice to understand what the docs are looking for or what's really important on those dipstick tests.

Also, don't forget to ask for a copy of your urinalysis reports.  It's another one of those test results it is nice to have a copy of so you know what is usual for you and to help plug info into a timeline.

Thanks DQ.  It's always good to have the hostess with the mostest at our party!
1253197 tn?1331212710
Hi Quix and a quick wuhuuu to see you posting again!

Top notch - incredibly clear and helpful explanation of all that I have been going through. I think that for each and every one of us our indvidual MS journey is unique. However there are many shared similiarities and all the examples and illustrations that you highlighted are horrible things that we all have experienced in varying degrees.

I still count myself as a relative newbie and am certainly gleaning as much as I can from this forum and I have learnt so much from you all. This helps me deal with my ongoing symptoms and I strongly believe that we all need to face and understand our condition to enable us to take action promptly when required such as when having a uti. As Julie mentioned I have been in relapse for a while and 5 weeks in, they found out I had a uti, i did not recognise the symptoms and hence delayed anti-biotics. BIG MISTAKE! I am convinced that if I had had them earlier I may have been feeling better earlier. However no point blaming anyone, but lesson learned for the future.

Your post is a definite must for a health page and well done once again for helping us all by explaining clearly what happens to the immune system when under attack and how it affects us.

Get better soon....you have had more than your fair share of challenges this year and deserve a break (but perhaps I should not say that in view of the recent fractures!!)

Love and hugs

Sarah x
147426 tn?1317269232
Two big comments here.

Sidesteps - I wondered if I should include allergies.  I do not have scientific data, just my own understanding of the immune system.  I have not read any reports of allergies causing relapses.  Any of you that are given to searching out the relevant scientific literature might look this one up.  

The allergic response is a specialized function of the immune system, dealing with a very specific type of antibody called IgE.  It also includes histamine producing cells called mast cells.  When an allergen (that protein that triggers the allergic response in primed individuals) contacts the mast cell, then the circulating IgE antibodies which are specific for that allergen bind to the allergen and BINGO! the allergic response.  The allegeric part of the immune system for the most part acts independently of the rest of the immune functions.  So when a bacterial infection occurs there is an immune response, but no increase in allergic response - usually.

I can't say this for all situations, because some infections will cause hives - most commonly strep throat and deep abcesses.

Still, my sense is that those of us with allergies are not at greater risk of relapses.

Anyone with different experience?

Mary - I use the same professional dipsticks that the labs use if they don't have a new-fangled machine which is more accurate.  Those are the Siemens Multi-Stix 10 SG.  When there is an infection you can see an indication in 4 areas:

Leukocyte esterase - this is an enzyme produced by the action of white pus cells called neutrophils.  When this is possitive it indicates the presence of large numbers of pus cells.  It has to be a clean catch, though, because the secretions from the vagina also have white cells commonly.

Nitrites - Nitrites are produced by bacteria as they multiply.  Heavy nitrites on the dipsticks indicate presence of bacteria.  Again, there are lots of bacteria in the vagina.  (MEn are so lucky sometimes)

Blood - There should not be blood in the urine.  The most common cause is an infection, but it can also mean other sources of irritation, cancer, kidney stones, etc.

Protein - An infection often will show higher levels than normal in the urine, but then so will exercise, dehydration and strong urine.

pH - Typically (but not always) an infection will make the urine more alkaline (less acidic) so the pH rises.  A pH near 8 is a good indicator there might be an infection.

Doctors HATE the fact that I use the Multistix stating that they are inaccurate.  They are but, they have never been wrong for me.  If the stick is positive in the first three of the measures then I ALWAYS have a UTI.  If my dipstick is negative, then so is the culture.

I get my sticks online, they are about $18 for a bottle of 100 sticks.

For me the best indicator of infection is a peculiar odor.  If I think I have whiffed it and the dipstick is negative or equivocal, then I hit the water and the cranberry tablets three times a day.  (BTW, the cranberry tablets can make the urine stink, too, but it is a different odor.)  Remember, I spent decades sniffing urine, poop, breath,  - but still they can be a help.  NEVER rely on the sticks in lieu of having your doc check the urine.

Another sign is cloudy urine.  I have an old chemistry beaker that I keep nearby.  Urine should always be clear (ie.  you can read ype through it).

Mary, you are correct.  We do well to keep a copy of all of our test results.

Sarah - At the very first sign of worsening symptoms or new ones my neuro ALWAYS orders a UA, a CBC and a basic Chem Panel.  He doesn't trust anyone's assessment of whether they might have an infection or not.  My Uro-Gyne says, "The MS bladder is a terrible historian!"

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