3. MS

Question 1

What is Multiple Sclerosis?

Answer 1

Autoimmune demylination of the CNS (brain and SC) at multiple sites in the CNS over space and time that causes periods of exacerbations and remissions of symptoms.

Question 2

Multiple Sclerosis

Symptoms (7)

Answer 2

• Can cause any neurological sign. Common ones are
  
  • 1. Paresthesias (tingling)
  • 2. Optic neuritis (pain and vision loss)
  • 3. Urinary problems/ Bladder dysfunction: spastic bladder and overflow incontinence
  • 4. Gait disturbances
  • 5. Dysarthria (slow and slurred speech)
  • 6. Hemiparesis (weakness on 1 side of body)
  • Transverse myolitis?!?!

Question 3

What are the 4 major types of MS?

In order from MC => LC

Answer 3

1. Relapsing and remitting (45-50%)
2. Secondary progressive (begin with relapsing and remitting type and still have some relapses)
3. Primary progressive
4. Benign

Question 4

Secondary progressive MS patients begin their disease process as which form?

Answer 4

Relapsing remitting

Question 5

When/who is MS most diagnosed in?

Answer 5

W 20-30; but often diagnosed from 15-50

Question 6

How is M.S affected by geographic region?

Answer 6

• ↑ risk depending on where you live before 14 YO:
• More common in
  
  • Temperate regions (Minneapolis, NY)
    Less common in
  • Tropical regions (FL, Miami

Question 7

The course of Multiple Sclerosis is most favorable in whom?

Answer 7

1. Women
2. Earlier onset (in 20s)
   
   1. *However, if really young (i.e., adolescent/early adult; 15YO) = unfavorable

Question 8

Which test can confirm the diagnosis of MS?

Answer 8

No single test can be used. Many tests are done:

1. MRI of the head and CT of the spine
2. Multimodality evoked potentials (SSEPs, VEPs, BAER)
3. Lumbar puncture of CSF

Question 9

What do you see on MRI of the head and CT of spine in MS patient?

Answer 9

1. MULTIPLE Ovoid lesions of high signal on T2WI in periventricular white matter and spinal cords
2. Acute lesions may enhance

Question 10

What do you see in CSF in MS patient?

Answer 10

1. Oligoclonal bands
2. ↑ IgG index/synthesis rate
3. ↑ proteins

Question 11

What causes M.S?

Answer 11

• Unknown:
  
  • Genetic susceptability
  • Childhood event sensitizes immune system to attack CNS myelin ==> adult event triggers the disease (viral infection or post-partum period)

Question 12

Only approved drug for patients with the Multiple Sclerosis: Primary Progressive type + relapsing forms of the disease?

Answer 12

Ocrevus

Question 13

Disease modifying drugs for M.S (slow the progression and ↓ amount and severity of exacerbations

Answer 13

1. IFN (interferons)
2. Glatirimer Acetate
3. Dimethyl Fumarate
4. • mabs
5. • mod
6. • mide
7. FINGOLAMOD?!

Question 14

Treatment of acute exacerbation in MS?

How does this affect the exacerbation?

Answer 14

• 1 gram of IV high-dose corticosteroid (methylprednisolone) for 3-5 days tapered with oral prednisolone
  
  • ↓ length of exacerbation, but does not change the outcome.

Question 15

If patient has an acute exacerbation of M.S and cannot tolerate steroids, what is another treatment?

Answer 15

1. ACTH (Acthar gel)
2. IVIg

Question 16

How is M.S diagnosed over space and time?

Answer 16

Multiple lesions over space and time

Question 17

What is a DDx of Multiple Sclerosis?

Answer 17

1. Clinicallly Isolated Syndrome (CIS): monofocal episode or multifocal episode

Question 18

What is a monofocal episode of Clinically Isolated Syndrome (CIS)?

Answer 18

Person experiences a single neurologic sign/symptom that’s caused by a single lesion (1 episode/1 time)

(i.e., optic neuritis in one eye)

Question 19

What is a multifocal episode of Clinically Isolated Syndrome (CIS)?

aka

Answer 19

Acute Disseminated Encephalomyelitis (ADEM)

• Person experiences more than one sign/symptom caused by lesions in more than one place (i.e., optic neuritis in one eye plus hemiparesis) one time.

Question 20

When CIS patients have multiple demyelinating lesions on MRI, they have a __________% chance of developing MS within several years?

Answer 20

• 60-80%
• *High risk

Question 21

When CIS patients do not have multiple demyelinating lesions on MRI, they have a ______% chance of developing MS within several years

Answer 21

• 20%
• *Low risk

Question 22

What are some conditions which can mimic MS?

Answer 22

1. Autoimmune disease: SLE w/ cerebritis or CNS vasculitis or Polyarteritis Nodosa w/ transverse myelitis
2. Devic’s disease (neuromyelitis optica)
3. B12 deficiency
4. Lymphoma or leukemia w/ CNS involvement
5. Spinocerebellar ataxias
6. Infections: HIV, West Nile, HTLV-1, CMV, Lyme disease, Syphillis
7. Granulomatous disease (sarcoidosis)
8. Metachromatic leukodystrophy, adrenomyeloleukodystrophy

Question 23

tx for management of spasticity in patients with MS?

(symptom-management drugs, NOT disease-modifying)

Answer 23

1. Baclofen (oral or intrathecal)
2. Tizanadine
3. Diazepam
4. Carbamazepine
5. Botox injections
6. Dantrolene

Question 24

Tx of intention tremors in patients with MS?

(symptom-management drugs, NOT disease-modifying)

Answer 24

1. Propanolol
2. Promidone
3. Clonazepam

Question 25

tx of **urinary urgency (spastic bladder)** in patients with **MS**? (symptom-management drugs, NOT disease-modifying)

Answer 25

1. **Oxybutinin** 2. **Detrol LA**

Question 26

tx **urinary retention/hesitency** in patients with **MS**? (symptom-management drugs, NOT disease-modifying)

Answer 26

1. **Bethanechol**

Question 27

tx **fatigue** in patients with **MS**? (symptom-management drugs, NOT disease-modifying)

Answer 27

1. Amantadine 2. - afinil 3. Bupropion 4. Methylphenidate 5. Pemoline 6. XRCISE

Question 28

What is **Devic's Disease** (aka?)?

Answer 28

* **Devic's Disease (NMO: Neuromyelitis Optica):** * Variant/different entity of M.S that is characterized by **inflammation** and **demyelination** of the **optic nerve** and **SC** (often LONG segments of SC), but spares the brain

Question 29

Fairly sensitive and specific test to diagnose **Devic's disease (aka NMO)?**

Answer 29

**Aquaphorin 4 antibodies** in blood and CSF

Question 30

What is the **general treatment** for Devic's Disease (aka NMO)?

Answer 30

1. **Steroids** and/or **plasma exchange (plasmapheresis)** 2. Followed by: **immunosupression** (i.e., azothiaprine, mycophenolate mofetil, or **_rituxumab_**)

Question 31

Why is it important to differentiate if **MS** or **Devic's Disease?**

Answer 31

**More aggressive, but treatable**