John Rinker II, MD

John R. Rinker II, MD
University of Alabama at Birmingham
Birmingham VA Medical Center
August 28, 2012

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.

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

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

56 y/o white male, born 1955
1973: Enlisted in the Army at age 18.
Served until 1975. No combat exposure.
1980: Re-enlisted into the Navy, where he
served until medically discharged in
1998

1981-84: Stationed at Camp Lejeune, NC.
Exposed to well water contaminated with
perchloroethylene (PCE) and
trichloroethylene (TCE) 1
1983: On-board helicopter involved in
the invasion of Grenada
1
VA has attributed at least 2 cases of cancer to this exposure

1990-91: 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

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.

Medical: PTSD
Social: Smokes cigarettes
Family: No history of MS or autoimmunity

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

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

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

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

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

Medical: PTSD; Migraines
Social: Cigarette use, ½ to 1 ppd; rare
alcohol, no illicit drugs
Family: No history of MS or autoimmunity

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.

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

April 2009 April 2011

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

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

If you would like to receive continuing
education credit for this activity, please
visit:
http://pva.cds.pesgce.com/