ClinMed - MS Flashcards
What is MS?
-immune mediated response by the body’s own immune system directed against the CNS
pathology progression of MS
- system attacks the myelin, fatty covering of nerve fibers
- myelin is damaged and scars form leading to degeneration and axonal death
- scars or degenerated area interrupt the electric signal conduction of the nerve
what are the 3 areas effects in MS?
- brain
- SC
- optic nerves
type of disease that classifies MS
demyelination
triad of risk factors for MS
- genetic risk
- environmental risk
- immunologic risk
enviromental risk factors
- low vit. D
- northern latitude
- smoking
- obesity
immunologic risk
- virus (EBV) trigger
- infectious agent
interesting stat about the epidemiology of MS
1:3 chance in monozygotic twins (not just genetic)
how to make the diagnosis of MS
- no single test
- best thing is MRI
- and get a good hx
- must be multiple events
criteria of MS diagnosis
-evidence of damage to at least 2 and separate areas of CNS
AND
-evidence that damages occurred at least 1 month apart
AND
-r/o other possibilities
what are the 3 possibilities to consider before establishing secure diagnosis?
- definite MS: meets mcdonald criteria
- probable MS: close to meeting mcdonalds + fam hx
- possible MS: doesn’t meet clinical or radiological criteria for definite diagnosis - this is a waiting game
mcdonald criteria
- review this in slides
- not sure if it would be testable?
Dawson fingers
- very classic MS lesions
- demyelinating plaques through corpus callosum
- right angles along medullary veins
- present as T2 hyper-intensities
Black holes
- hypointense lesions commonly seen in MS
- indicates destruction, axonal loss and relatively severe CNS damage
- seen in T1 modality
GAD enhancing lesions
- during active inflammation, the BBB is disrupted
- allows the gadolinium to pass through
- GAD can enter CNS and leak into the new lesion
- “new lesion” = in the past 6-8 weeks
describe an acute cord lesion
- GAD enhancement
- spinal cord spelling
describe a chronic cord lesion
- cord atrophy
- greater disability
Ddx in MS
- AVM
- other autoimmune: lupus, sjogren’s, sarcoidosis, ADEM, NMO
- B12 or Cu deficiency
- infection: lymes, syphilis, HIV
- malignancy
- migraine
general clinical manifestation categories of MS
- eye
- vertigo
- ataxia
- SC sx
- cortical signs
clinical manifestions of MS in the eye
- optic neuritis
- nystagmus
- diplopia
optic neuritis
- painful eye movement
- decrease in visual field
- decrease in color saturation
clinical manifestation of vertigo
- associated w/ adjacent structures
- increased/decreased hearing
- facial numbness
- diploplia
clinical manifestations of ataxia
- truncal: poor sitting balance
- limb: finger to nose, intention tremor
clinical manifestations of SC
- nerve pain
- L’Hermitte sign (when they tuck chin they feel electric shock over cape distribution)
- neurogenic bladder > bowel
- sexual dysfunction
- weakness then spasticity
- hyperreflexia
clinical manifestations of cortical signs in MS
- poor mood
- migraine
- seizure
- cognitive changes
sub types of MS
- relapsing remitting (MS)
- secondary progressive
- primary progressive
relapsing course of MS can be . .
- active or inactive
- worsening or not worsening
progressive courses of MS can be . .
- active w/ or w/o progression
- non active w/ or w/o progression
what falls under the umbrella term of probable or possible MS?
- CIS (clinically isolated syndrome)
- RIS (radiologically isolated syndrome)
CIS
- first attack
- one scar seen
- one exam finding
RIS
- incidental finding when MRI is done for another reason
- immuno therapy is a weighted decision here
- +/- fam hx of MS is helpful
what is the goal of immuno therapy?
- decrease future disability
- reduce future lesion formation
*no cure for MS and even w/ immunotherapy there can still be further lesion formation
MS tx options
- injections
- oral
- infusions
- vitamins
- IMT
injection txs
- Avonex 30 mg im q week
- Betaserone .25 mg sc QOD
- Copaxone 40 mg sc M/W/F
- Rebif 22, 44 mcg sc M/W/F
oral meds
– Fingolimod (Gilenya) 0.5mg qd
– Dimethyl fumerate (Tecfidera) 120, 240mg bid
– Teriflunomide (Aubagio) 7, 14mg qd
infusion tx options
- lemtrada: destroys T, NK cells and monocytes
- tysabri: prevents CNS lymphoctes migration through the BBB
- ocrevus: destroys b cells
- novantrone: destroys t cells
- rituxan: destroys b cells
vitamin supplement tx
- cholecalciferol (D3)
- 2,000 - 4,000 IU daily
what is the lab value goal for vit. D3?
70+
nl is lower than that but want these pts high
making a decision on using IMT tx
- pts disease course
- benefits vs risk of each med
- co morbitities
- contraindications
- cost
- pt preference
- pt readiness
acute relapse
- new sx or sudden change in old sx lasting at least 24 hrs w/ an objective neurological change on exam
- get GAD enhancing MRI
what to r/o in relapse
- r/o pseudo relapse
- ie: infectious, metabolic or psychologic stressor which mimics an acute relapse
Uhthoff’s phenomenon
- the worsening of neurologic sx in MS when the body gets over heated
- could be d/t: hot weather, exercise, fever, saunas, hot tubs
- keep in mind for psuedo relapse
tx of acute relapse
- 3-5 day admission for IV methylprednisolone
- PT/OT to restore function
scale used for MS disability
- Kurtzke scale
- 1-10
- 6 is the cut off for increasing disability
MS accessory sx
- widely variable from person to person and time to time
- inclue: fatigue, sensory loss, visual changes, pain, depression, and many more
common temp issue in MS?
heat sensitivity
heat sensitivity in MS
- often causes increased fatigue, weakness, visual disturbance
- any previous sx may be temporarily worsened w/ heat exposure
- cold sensitivity could also occur
muscle weakness in MS
- often in distal upper extremities
- common in lower extremities: hip and knee flexion, ankle dorsiflexion
- disuse weakness
tx for muscle weakness
- rehab/exercise
- dalfampridine
- mobility aids
ataxia in MS
- lack of voluntary coordination of muscle movements
- clumsiness, unsteady gait, impaired eye and limb movemens and speech problems
- might be seen as tremor
tx of ataxis
dalfampradine in some cases
fatigue in MS
- exclude non-MS reasons
- review meds
- energy management
- exercise program
meds used off label for fatigue in MS
- amantadine
- monafinil, armodafinil
- CNS stimulants
mobility in MS
- need early referral to rehab
- goal is to promote function, comfort, and independence
mobility aids
- they conserve energy, enhance safety and allow people to remain active
- cane, crutches, walker, etc.
drug approved to improve walking speed in MS
dalfampridine
bladder dysfunction in MS
- check for infection
- assess lifestyle
- consider early referral to urologist
small bladder issue (failure to store) tx
- Anticholinergic
- pelvic flood PT
- botox
- nerve stimulation
large bladder issue (failure to empty) tx
-intermittent self cath
tx for contipation in MS
- regular bowel regimen
- high fiber diet
- sufficient liquids
- bulk formers
- stool softeners
- avoid harsh laxatives and enemas
tx for incontinence in MS
- possible need for GI consult
- Anticholinergic meds used for bladder
- fiber w/ small amounts of water
pharmacological tx for dysesthsia and paresthesia pain in MS
- gabapentin
- lamotrigine
- carbamazepine
- amitriptyline
- pregabalin
- others
other tx for pain in MS
- gloves, counter irritants
- acupuncture
- biofeedback
orthopedic / spasticity pain tx
- PT
- NSAIDs, acetaminophen, baclofen
depression in MS
- suicide much more common
- over half will have major depressive episode
- need to be regularly screened for MS
cognitive impairment in MS
- mild is common
- MS affects:
- brain volume
- gray matter
- cerebral cortex (the scars pull it down)
overall prognosis
- no definite one
- highly variable and unpredictable
favorable prognostic factors
- early visual or sensory sx
- onset before age 40
- female
- relapsing forms
unfavorable prognostic factors
- early cerebellar or motor sx
- onset after 40
- male
- progressive forms
primary care provider role in MS
- early recognition for timely diagnosis
- referral to specialty:
- neuro
- mental health
- urologist
- rehab
- speech/language/path
review
case studies at end of lecture
