[5] Multiple Sclerosis Flashcards
What is multiple sclerosis (MS)?
A cell-mediated autoimmune condition characterised by repeated episodes of inflammation of the nervous tissue in the brain and spinal cord
What is the result of the inflammation of the nervous tissue seen in MS?
Loss of the insulating myelin sheath
What cells are lost in MS?
Oligodendrocytes
What are oligodendrocytes responsible for?
Creating and maintaining the myelin sheath
What is the effect of MS on the myelin sheath?
Causes thinning and eventually complete loss
When may MS affect the axons of the neurons?
In advanced disease
What is the result of the loss of myelin in MS?
Less effective conduction of electrical signals
How is loss of myelin handled in early MS?
Remyelination occurs
Why is remyelination not involved later in MS?
It becomes less effective after repeated attacks and eventually scar-like plaques build up around the axon
What are the three main characteristics of MS?
- Formation of plaques in the CNS
- Inflammation
- Destruction of the myelin sheath
Does MS form plaques in the white or grey matter?
White matter
White matter in what parts of the nervous system are commonly affected in MS?
- Optic nerve
- Brain stem
- Basal ganglia
- Spinal cord
- Peri-ventricular
What cells cause the inflammation in MS?
T cells
What happens as a result of the inflammation caused by attack of the myelin?
Other immune cells are signalled and factors such as cytokines are released, worsening the problem
What are the three different patterns of MS?
- Relapsing-remitting
- Primary progressive
- Secondary progressive
What is the pattern of disease in relapsing-remitting MS?
The disease comes and goes with occasional irrecoverable loss of function in some relapses
What percentage of patients with MS have relapsing-remitting at first onset?
80%
What is secondary progressive MS?
Gradually worsening symptoms with fewer relapses that follows on from relapsing-remitting MS
What percentage of patients with relapsing-remitting MS go on to develop secondary progressive within first 10 years?
50%
What is primary progressive MS?
Gradually worsening symptoms from the beginning with no remission
What percentage of MS patients have primary progressive from onset?
10-15%
What factors can have an influence on the development of MS?
- Genetic factors
- Environmental e.g. early viral infections
What are the risk factors for MS?
- Family history
- Smoking
- Vitamin D deficiency
- Autoimmune disease
- EBV
What are the common initial features of MS?
- Loss of vision in one eye with painful eye movements
- Diplopia
- Ascending sensory disturbance and/or weakness
- Altered sensation down the back and sometimes into the limbs
What are the common features in the history in a patient presenting with MS?
- Often <50
- History of previous neurological symptoms
- Symptoms evolving over more than 24 hours
- Symptoms persisting and then improving after a few weeks
What neurological signs or symptoms can present in patients with MS?
Almost any
What are the more common types of neurological symptoms in MS?
- Autonomic
- Visual
- Motor
- Sensory
How can the main symptoms of MS be divided?
- Central
- Visual
- Speech
- Throat
- MSK
- Sensation
- Bowel
- Urinary
What are the central symptoms of MS?
- Fatigue
- Cognitive impairment
- Depression
- Anxiety
- Unstable mood
What are the visual symptoms of MS?
- Nystagmus
- Optic neuritis
- Diplopia
Why is optic neuritis an important symptom in MS?
It is often a first presenting symptom
Give one speech and one throat symptom of MS?
- Dysarthria
- Dysphagia
What are the MSK symptoms of MS?
- Weakness
- Spasms
- Ataxia
What are the sensation symptoms of MS?
- Pain
- Hypoesthesia
- Paraesthesia
What are the bowel symptoms of MS?
- Incontinence
- Diarrhoea and constipation
What are the urinary symptoms of MS?
- Incontinence
- Frequency or retention
What blood tests should be made in order to rule out differentials for MS before referring to a neurologist?
- FBC
- Inflammatory markers
- U&E’s
- LFTs
- TFTs
- Glucose
- HIV serology
- Calcium and B12 levels
How should investigations be used in diagnosing MS?
To support diagnosis with clinical features
What investigations can be used to support a diagnosis of MS?
- Electrophysiology
- MRI
- Lumbar puncture
What is the use of electrophysiology in MS investigation?
It can detect demyelination in apparently unaffected pathways
What abnormalities can be seen on MRI in MS?
- Periventricular lesions
- Discrete white matter abnormalities
- Plaques of the optic nerve, spinal cord and brainstem
What percentage of patients with MS have periventricular lesions on MRI?
95%
What percentage of patients with MS have discrete white matter abnormalities on MRI?
90%
How can active inflammatory plaques be distinguished from inactive ones?
Using a contrast agent
How does the number and size of the lesions correlate to disease activity or progress?
Poorly
What can an LP show in MS?
Rise in total CSF protein with increased immunoglobulin concentration and oligoclonal bands
What are the differentials for MS?
- Hereditary spastic paraplegia
- Cerebral variant of SLE
- Sarcoidosis
- Myelopathy
- Fibromyalgia
How can the management of MS be divided?
- Treatment of relapses
- Disease modifying therapy
- Treatment of symptoms
What is the main drug type used to manage relapses in MS?
Corticosteroids
What is the standard steroid therapy for relapses of MS affecting functioning?
IV methylprednisolone
If patients cannot take methylprednisolone IV what alternative is available?
High dose oral methylprednisolone
Who should be consulted for starting high dose oral methylprednisolone in MS?
Specialists
How long is typical methylprednisolone for MS relapses?
3-5 days
What care must be taken when using high dose methylprednisolone for MS?
- Look for signs of infection
- Check blood sugars in diabetics
What may benefit MS patients with severe or rapidly progressing disability?
Plasma exchange with or without IV steroids
Which type of MS are DMARDs useful for?
Relapsing-remitting MS (sometimes secondary progressive)
What are the first-line option DMARD’s for MS?
- Interferon beta
- Glatiramer
- Dimethyl fumurate
- Teriflunomide
- Alemutuzab
When should DMARD’s be used in relapsing-remitting MS?
During active disease
What is considered active relapsing-remitting MS?
At least 2 attacks of neurological dysfunction over the previous 2 years, followed by complete or incomplete recovery
Who can interferon beta be used in to treat MS?
- Those with active relapsing-remitting who can walk 100m unaided
- Those with secondary progressive MS
How is interferon beta administered for MS?
SC or IM injection on alternate days, 3 times/week, or weekly
What are the most common side-effects of interferon beta?
- Flu-like ague
- Injection site reactions
What is ague?
A fever, or shivering fit
Who can glatiramer be used in to treat MS?
Those with active relapsing-remitting disease
How is glatiramer administered to treat MS?
Daily SC injections
What are the common side-effects of glatiramer?
- Flu-like symptoms
- Injection site reactions
Who can dimethyl fumarate be used in to treat MS?
Those with active relapsing-remitting MS but only if they don’t have rapidly evolving disease
How is dimethyl fumarate administered to treat MS?
Orally, BD
Who can teriflunomide be used in to treat MS?
Those with active relapsing-remitting MS but only if they don’t have rapidly evolving disease
Who can alemtuzumab be used in to treat MS?
Those with active relapsing-remitting disease
What symptoms of MS should be managed?
- Fatigue
- Pain
- Visual problems
- Speech difficulties
- Weakness and cardiorespiratory fitness
- Spasticity and spasms
- Ataxia and tremor
- Pressure ulcers
- Urgency or urge incontinence
- Constipation
What can be the underlying causes of fatigue in patients with MS?
- Depression
- Pain
- Medication
How can fatigue be managed in MS?
- Amantadine
- Mindfulness
- CBT
What can cause pain in MS?
- Neuropathic pain
- MSK pain secondary to immobility
How should neuropathic pain be managed in MS?
- Anticonvulsants e.g. gabapentin
- Antidepressants e.g. amitryptilline
How can MSK pain be managed in MS?
- Standard analgesic pain ladder
- TENS
- Anti-depressants e.g. amitryptilline
What is the usual cause of visual problems in MS?
Poor control over eye movements
What else should patients with poor vision in MS be assessed for?
Need for glasses
What can be offered to MS patients with nystagmus causing reduced visual acuity?
Trial of oral gabapentin
What non-medical management strategies bay me needed for MS patients with visual problems?
- Low-vision equipment
- Adaptive technology
- Registered as sight impaired
How can speech problems be managed in MS?
Referral to SALT
How can weakness be managed and cardiorespiratory fitness maintained in MS?
- Exercises and techniques to maintain strength
- Equipment
- Physiotherapy
What can aggravate spasticity and spams in MS?
- Pain
- Infection
What can help spasticity in MS?
- Passive stretching
- Baclofen
- Gabapentin
How should ataxia and tremor be managed in MS?
Specialist referral
Why are MS patients at high risk of pressure ulcers?
- Limited mobility
- Impaired sensory function
- Impaired cognition
How can urge incontinence be managed in MS patients?
- Conveen for men
- Pads for women
- Anticholinergics e.g. oxybutynin
- Intermittent self-catheterisation can be considered
What can be used to manage constipation in MS?
Routine suppositories and enemas
What are the potential complications of MS?
- Muscle stiffness and spasms
- Paralysis
- Bowel, bladder or sexual dysfunction
- Changes in mental status
- Epilepsy
- Osteoporosis
- Pressure sores
- Inflammation of lungs
- Severe UTIs
