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“All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.” Arthur Schopenhauer (1788–1860)
Associations of environmental agents and MS have gone through the first and second stages of Schopenhauer’s “truth” but have not yet attained the stage of acceptance. For more than 50 years environmental triggers, typically viruses, have been implicated in the etiology of MS.1,2⇓ The epidemiology of MS supports an environmental agent. There is evidence of MS clustering,3 and MS increases in incidence with distance in either direction from the equator. Migration away from high prevalence areas before adulthood decreases the likelihood of developing MS. In addition, genetic factors alone are insufficient to cause MS. Despite a clear genetic influence in MS (the rate of concordance is eight times greater in monozygotic than dizygotic twins),4,5⇓ the concordance rate among monozygotic twins remains only 25%. An increased risk of MS has also been observed in persons developing childhood infections as adults.1 Demyelinating animal models exist in which viruses with long incubation periods cause relapsing neurologic disorders,1,6⇓ some of which are immune-mediated. Similar immune reactivities to a number of viruses have been reported in patients with MS.7 Increased antibody titers to a variety of infectious agents …
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