B6.042 MS Big Case Flashcards
definition of MS
a chronic disease of the CNS characterized by intermittent episodes of neurologic dysfunction, separated in space and time
caused by inflammation and subsequent demyelination in the white matter
epidemiology of MS
symptoms around ages 20-45
3:1 women: men
more common in northern latitudes
20% of MS patients have a relative with MS
very prolonged course - typically many years
early symptoms of MS
blurred vision in one eye (optic neuritis) diplopia numbness and tingling bladder control problems vertigo weakness of specific limbs fatigue Lhermitte's Sign
what is Lhermitte’s sign
electric shock feeling when bending forward or backwards
-sensation travels into limbs or back
indication of c-spine damage
chronic ongoing symptoms of MS
early symptoms PLUS spasticity depression weakness/ paralysis oscillopsia gait abnormalities tremor optic atrophy sphincter disturbance (bladder, sometimes bowels) sexual dysfunction pain coordination problems cognitive changes
what is oscillopsia
sees their own nystagmus
unusual problems seen in MS
seizures bowel incontinence trigeminal neuralgia altered consciousness (comatose spell) mimics a brain tumor hearing loss involuntary movements narcolepsy
definition of an MS “attack”
an episode of acute neurologic dysfunction, or worsening of a previous dysfunction, lasting more than 48 hours, not caused by metabolic changes in condition
common early exam findings
optic nerve pallor internuclear ophthalmoplegia nystagmus reflex asymmetry babinsky and Hoffman signs absent abdominal reflexes spasticity asymmetrical weakness gait instability/ foot drop numbness of LE or on one side of body
what types of sensations are typically lost with MS?
vibration and proprioception more commonly diminished due to being transmitted via type 1 myelinated fibers
pinprick and temperature less commonly affected bc they are transmitted by type 4 fibers which are less myelinated at baseline
common later exam findings in MS
dysarthria
tremor
moderate to severe gait disturbances with leg drag, incoordination, spasticity
clumsiness of the hands
bilateral INO (internuclear ophthalmoplegia)
exam findings in severe, late MS
reduced voice production
difficulty with swallowing
quadriparesis
severe clumsiness of hands with tremor
diagnostic testing in MS
start w physical exam
MRI scans of brain, cervical, and thoracic spine (not lumbar spine, no spinal cord present)
lumbar puncture
OCT
characteristics of MRI in MS
white matter lesions seen in 95% of people with clinically definite MS
often periventricular, juxtacortical or present in posterior fossa
white matter lesions in general population
10-15% normal patients under 50 have these lesions
seen in a large number of patients over age 50
also seen in patients with DM, SLE, smoking, HTN, other WM diseases of CNS
lumbar puncture findings in MS
protein may be normal or moderately elevated
possibly increased WBC, mainly mononuclear cells, up to 50 (if higher, think infection)
oligoclonal bands present in 85%
increased IgG index in 70-80%
increased IgG synthesis in 70-80%
myelin basic protein elevated during an attack
types of MS
relapsing primary progressive secondary progressive progressive relapsing transitional MS benign MS
relapsing MS
episodes of acute or subacute neuro changes
remission from these episodes, variable in speed and completeness
general trend is toward accumulation of permanent disability over time
secondary progressive MS
course begins as a relapsing types of MS
after some time, neurologic abnormalities begin to worsen slowly without true attacks
some patients still have attacks
occurs in 40-60% of patients with relapsing MS
speed of progression is variable
primary progressive MS
patient never has acute or subacute episodes
progressive deterioration of CNS function from the beginning of the illness
extremely variable in speed of progression to cause disability either in a few months or over many years
stabilizes at some point
progressive relapsing MS
patient who has a progressive course from the beginning, but also some episodes of acute or subacute neurologic dysfunction with partial recovery
treatment of an MS exacerbation
methylprednisolone 500-1000 mg IV daily for 3-10 days
prednisone taper options
ACTHar gel
rehab measures
**Steroids do not affect final outcome of relapse, only the speed of imporvement
what is a pseudo-exacerbation of MS
an episode of worsening of current MS symptoms or recurrence of previous symptoms brought on by a metabolic or emotional disturbance, fatigue, or heat
- treatment is usually rest and treatment of the underlying disturbance
- one of the most common causes of sudden worsening in progressive patients
effects of immunomodulators/ immunosuppressants on MS
reduce frequency of attacks thereby often reduce progression of the disease
don’t always work
generally a reduction of 50% in attack frequency from placebo
not expected to improve patient from baseline
not a cure!
risk of immunosuppressive agents
increased risk of infections liver abnormalities GI abnormalities fatigue possible cancer risks- skin cancers, leukemias/ lymphomas, and breast cancer with ocrelizumab
decision making w disease modifying drugs
match severity of disease with the invasiveness of treatment
injectables have good long term safety records with good efficacy, but may not be quite as potent as oral meds
infusions most effective but most risky
treatment for progressive disease
meds are not usually useful to slow progression
patients still experiencing relapses may benefit from continuing immunomodulators
sometimes its best to stop trying to treat bc continued infections may actually speed progression of MS
ocrelizumab in progressive disease
shown to work in early primary progressive MS with modest effect
other agents tried for progressive MS
azathioprine
methotrexate
cellcept
pulse solmedrol
symptom management of MS
important in maintaining quality of life
need to be aware of too many meds and their interactions
good health measures to aid in MS quality of life
aerobic exercise good healthy balanced diet maintain ideal body weight take general good care of health calcium and vit D PT and OT
