CBL - MS

Question 1

What are the signs of optic neuritis? [3]

Answer 1

1. red desaturation
2. relative afferent pupillary defect on one eye
3. optic disc pallor on one eye implying optic atrophy

Question 2

What is Hoffman’s sign? [2]

Answer 2

1. upper motor neurone (UMN) sign
2. parallels the extensor plantar sign in the lower limb
3. +ve when there is flexion of the ipsilateral thumb after tapping the nail bed of the 3rd finger

Question 3

What are the upper motor neurone (UMN) signs that can be seen in the limbs? [6]

Answer 3

1. increased tone in a spastic pattern
2. weakness
3. hyper-reflexia
4. clonus
5. extensor plantars
6. positive Hoffman’s sign

Question 4

What parts of the nervous system does MS usually affect and what clinical signs would be present due to a defect in each of these areas? [4]

Answer 4

1. optic nerve
   
   • optic neuritis
2. brainstem
   
   • ataxia
   • swallowing problems
   • eye movement problems
3. spinal cord
   
   • bladder problems
   • constipation
   • limb weakness
4. white matter hemispheric regions
   
   • motor problems
   • sensory problems

Question 5

What finding in the CSF would indicate MS? [1]

What other condition can this finding also be present in? [1]

Answer 5

presence of oligoclonal bands in CSF (but not in the blood)

can also indicate sarcoidosis

Question 6

What is the difference between a diagnosis of MS and a diagnosis of clinically isolated syndrome? [2]

Answer 6

1. MS is diagnosed when there are 2 neurological lesions which are disseminated in space and time
2. Clinically isolated syndrome is diagnosed when there is a single presentation of optic neuritis with a normal MRI

Question 7

What is VERS and what does it show? [2]

Answer 7

1. visual evoked responses
2. measures the speed at which impulses travel along the optic nerve
3. if delayed, this indicates optic neuritis

Question 8

The McDonald criteria for MS requires dissemination in space, with a lesion in at least 2 of what locations? [4]

Answer 8

1. periventricular (around the ventricles)
2. juxtacortical (at the grey:white matter junction)
3. infratentorial (e.g. cerebellum)
4. spinal cord

Question 9

What are the disease modifying treatment options for relapsing remitting MS? [7]

Answer 9

First line treatments

• Injectable treatments
  
  • beta interferons
  • glatiramer acetate
• Oral treatments (immunosuppressants)
  
  • dimethyl fumerate
  • teriflunomide

Second line treatments

• fingolimod (stronger oral agent)
• atalizumab (monoclonal antibody)

Third line treatments

• alemtuzumab (powerful monoclonal antibody) that essentially resets the immune system and can eliminate MS relapses

Question 10

Dimethyl fumerate:

1. mechanism of action? [2]
2. side effects? [3]

Answer 10

1. mechanism of action:
   
   • suppresses immune system
   • reduces lymphocyte counts
2. side effects:
   
   • flushing
   • GI side effects
   • potentially serious infections

Question 11

What are the treatment options for progressive MS? [3]

Answer 11

SYMPTOM CONTROL

1. fatigue
   
   • if disease related, modafinil or amantadine may help
2. urinary symptoms
   
   • storage dysfunction:
     
     • anti-cholinergic agents (oxybutynin)
     • botox
   • emptying dysfunction:
     
     • self-catheterisation
     • tamsulosin
3. spasticity
   
   • physiotherapy
   • drugs include gabapentin, benzodiazepines etc.