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Neuro Behavioral Med I > 8 - Multiple Sclerosis > Flashcards

8 - Multiple Sclerosis Flashcards

1
Q

What is multiple sclerosis?

A
  • Leading cause of non-traumatic brain disease in young people
  • Characterized by episodes of focal disorder of the central nervous system
  • Demyelinating and axonal disease
  • Affects the white matter predominately, but also affects the grey matter
  • An autoimmune disease (but not a classic autoimmune disease)
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2
Q

What type of nerological findings will you see in MS?

** TAKE HOME **

A

MS only gives you upper motor neuron findings

NOT both upper and lower

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3
Q

Which part of the brain does it affect the most?

A

White matter

But also grey matter - BOTH

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4
Q

What type of a disease is MS predominately?

A

Demyelinating

But also, axonal disease - BOTH

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5
Q

Describe MS as an autoimmune disease

A

(but not a classic autoimmune disease)

- More of an autoimmune-mediated disease

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6
Q

Describe the epidemiology of MS

A
  • Approximately 400,000 Americans are afflicted with M.S.

- Peak age of onset is about 30(typical range 18-55)

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7
Q

What factors contribute to MS?

A

Unknown etiology

  • Geographical factors
  • Familial factors (but not a strict Mendelian inheritance)
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8
Q

What is the gender variation in MS?

A

Ratio of females to males is 2-3:1 in the United States

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9
Q

What is the geographical variation in MS?

A

Geographical variation:

- Incidence of M.S. increases with increasing latitude

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10
Q

Describe the etiology of MS

A
  • The cause of multiple sclerosis remains unknown
  • Neurotropic viruses, bacteria and numerous environmental toxins have been implicated.
  • EBV (Epstein Barr virus) titers are present in almost all MS patients and levels are increased during acute MS attacks.
  • 80% have had exposure to EBV, but unknown if this is the case
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11
Q

Describe the genetics that contribute to MS

A
  • Prevailing hypothesis is that M.S. is a polygenic disease
  • Only one genetic factor of confirmed importance- HLA class II region of chromosome 6
  • Predominantly a disease of caucasians
  • 20% of patients have a family history of at least one additional case of M.S.
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12
Q

What is the risk of other family members getting MS?

A
  • High concordance rate of 30% in monozygotic twins
  • 2-6% risk with a full first degree relative
  • 1.1-1.4% risk with a half sibling
  • Adoption and general population (0.1%)
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13
Q

What is the gene that is the most implicated in MS?

A

HLA class II regions

  • HLA-DR-DQ haplotype HLA-DRBI*1501
  • DRB50101, DQA10102, DQB1*0602 increases the risk for M.S. three to four times
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14
Q

Describe the immunological attack seen in MS

A
  • Predominantly an aberrant T-cell immune response(B-cells and macrophages play a lesser role)
  • Activation of circulating CD4 cells specific for myelin basic protein, proteolipid protein, MOG, and MAG.
  • Dysfunction in the BBB allowing the activated cells to cross into the CNS attacking myelin.
  • A normal BBB would not allow cells to cross, so there is a defect in the BBB of MS patients
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15
Q

What are the four types of clinical courses of MS?

A
  • Relapsing-remitting MS
  • Primary progressive MS
  • Secondary progressive MS
  • Progressive relapsing MS
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16
Q

What type do 85% of patients have at diagnosis?

A

Relapsing-remitting MS

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17
Q

What type of MS do we have good treatment for?

A
  • The active, relapse form (attacks of MS)

- No good treatment for just primarily progressive MS

18
Q

What is the disease severity we see with MS?

A

Disease Severity:

  • Benign 10-20%
  • Malignant 10%
  • Intermediate 70-80%
19
Q

How do you know which type your patients will have?

A

Prognostic indicators

20
Q

What are the poor prognostic indicators?

A

Poor prognostic indicators

  • male
  • older age at onset
  • posterior fossa symptoms at onset
  • African-American
  • Significant residual disability from first attack
21
Q

How do you diagnose MS?

A

It is a diagnostic challenge

  • No blood test
  • History
  • Neurologic Exam
  • M.R.I. (FLAIR, Gad, spectroscopy)
  • CSF studies (IgG is highly indicative of MS)
  • Evoked potentials (visual evoked response test)
22
Q

What is key?

** TAKE HOME **

A

HISTORY
- If you have taken a history and you have no clue and you think the testing is going to tell you, you need to go back and take a better history

23
Q

What do you need to listen to in the clinical history diagnosis?

A
  • Age, race, gender, rearing

- Symptoms referable to the CNS

24
Q

What do you need to do in the neurological exam when diagnosing MS?

A
  • Signs referable to the CNS

- Solid findings such as extensor plantor responses, RAPD, INO, optic disk edema more helpful

25
Q

What do you look for on an MRI scan when looking for MS?

A
  • Spots in the corpus collosum
  • Light spots in the middle of the brain
  • These are lesions in the brain and can indicate MS
  • These spots could be caused by a stroke or something else when seen throughout the brain
  • If you see it in the corpus collosum specifically, be highly suspicious of MS
26
Q

What do you look for in teh spinal fluid when looking for MS?

A
  • Pleocytosis of typically less than 50 wbc and only very rarely above 100 wbc
  • Non-specific elevation in protein
  • Elevated IgG synthesis rate
  • Presence of oligoclonal IgG bands

You should NOT have antibodies and immune cells in the brain, so it indicates a breech in the BBB

Remember IgG ***

27
Q

What “evoked potetials” will you see in the physical exam on an MS patient?

A
  • VER most helpful ***
  • BAER-possibly helpful if brainstem lesion suspected
  • SSEP-possibly helpful if spinal cord lesion suspected
28
Q

What is Neuromyelitis Optica?

A

AKA Devic’s disease

An ONLY B-cell mediated disease

29
Q

Describe the features of neuromyelitis optica

A
  • B-cell mediated disease
  • Aquaporin-4 ab (NMO-IgG)
  • Transverse myelitis and often bilateral O.N.
  • Initial cranial MRI often normal
  • Longitutinally extensive spinal lesions (very big lesions)

Often times blind and quadraplegic

30
Q

What is acute disseminated encephalomyelitis?

A

ADEM

  • Febrile illness
  • Much more common in children
  • Typically involves grey and white matter of the CNS
  • Typically monophasic
31
Q

What drug can you use in MS patients to improve gait?

A

AMPRYA (4-aminopyridine)

32
Q

How does AMPRYA (4-aminopyridine) improve gait in MS patients?

A
  • Showed improvement in gait based on 25 foot timed walk.
  • May reduce motor fatigue
  • Sustained release prep is well tolerated
  • Sz
33
Q

What is very common for MS patients to take?

A

Supplements

Always ask!

34
Q

What is the ONLY supplement that is recommended?

A

Vitamin D

Proven effects!

35
Q

Describe the effects of vitamin D on MS

A
  • Recent study showed an association of low 25-hydroxyvitamin D levels with an increased incidence of M.S.
  • EAE treated mice exhibited a less severe disease course when treated with Vitamin D.
  • Osteoporosis/ osteopenia are under-diagnosed and under-treated in MS. Treatment with Calcium/ Vit D is recommended
  • Recommend serum D level of ~50.
36
Q

What is the other actual treatment of MS?

A

Immunomodulation

37
Q

What are the immunomodulation options?

A
  • Beta interferon therapy
  • Glatiramer acetate
  • Mitozantrone
  • Natalizumab
  • Fingolimod

There are risks associated with each of these

38
Q

Some of these have become available as a pill. What are the benefits and issues with this?

A
  • The pills have tolerance issues that shots do not have
  • Other side effects like GI and diarrhea can be present
  • However, patients can get “needle fatigue” and get sick of always taking shots, so a pill is nice for them
39
Q

Describe the drug research focus currently

A

We are focused on repair of the neurological system

40
Q

What is the first drug that has been shown to be effective in primary progressive MS?

A

LISTEN ***

At the very end

Neuro Behavioral Med I (15 decks)

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