Inflammation and infection

Question 1

What is multiple sclerosis?

Answer 1

Autoimmune demyelination of the central nervous system
Onset 20-40yrs

Predominantly affects the white matter
Has multiple relapses

Doesn’t cause death directly, more due to immobility effects

Question 2

What are some symptoms of Multiple sclerosis?

Answer 2

• Sensory loss (early)
• Spinal cord symptoms:
  Motor: Muscle cramping secondary to spasticity
  Autonomic: Bladder, bowel, and sexual dysfunction
• Cerebellar symptoms - Charcot triad of dysarthria (scanning speech), nystagmus, and intention tremor
• Optic neuritis
• Trigeminal neuralgia - Bilateral facial weakness or trigeminal neuralgia
• Facial myokymia (irregular twitching of the facial muscles) - May also be a presenting symptom
• Eye symptoms - Including diplopia on lateral gaze; these occur in 33% of patients
• Heat intolerance
• Constitutional symptoms - especially fatigue (which occurs in 70% of cases) and dizziness; fatigue must be differentiated from depression (which may, however, coexist), lack of sleep, and exertional exhaustion due to disability
• Pain
• Cognitive difficulties
• Depression
• Euphoria - Less common than - Depression
• Bipolar disorder or frank dementia

Question 3

What is the difference between grey and white matter?

Answer 3

White matter is the connections for the grey matter

Question 3

How is MS diagnosed?

Answer 3

Prove changes with MRI and take CSF that shows oligoclonal bands and bloods for systemic inflammation

Because MS is and autoimmune disease of the CNS

Question 4

How is MS managed?

Answer 4

Acute relapse: steroids and immunomodulation (disease modifying treatment)

Treat symptoms

Question 5

What is Baclofen used for in MS?

Answer 5

First line for spasticity

Question 6

What is Guillain-Barré
syndrome?

Answer 6

Autoimmune demyelination of peripheral nerves

Develops 2-4 weeks after a respiratory or GI infection

Can cause death because is affects swallowing and breathing

Question 7

Which cells contain the myelin in the CNS compared to the PNS?

Answer 7

CNS: Oligodendrocytes
PNS: Schwann cells

Question 8

What are some symptoms of Guillain-Barré syndrome?

Answer 8

Symmetrical symptoms
Paraesthesia
Dysphagia
Weakness ascending from legs up
Autonomic dysfunction

Better outcome if diagnosed early

Question 9

How is Guillain-Barré syndrome diagnosed?

Answer 9

Prove disease in PNS that is autoimmune
Nerve conduction study equivalent to MRI scan in MRI
High protein in CSF (cauda equina in PNS)

History + examination
Eg. absent reflexes (unlikely to be GBS if present), flaccid paralysis, reduced power and sensation
(Everything is reduced)

Question 10

How is Guillain-Barré syndrome treated?

Answer 10

Steroid don’t work
DMARDS are too slow

Give IV immunoglobulin to destroy the bad antibodies or do plasma exchange

Treatment needs to be rapid and getting rid of the bad antibodies is key

Question 11

What is Giant cell arteritis?

Answer 11

Autoimmune
Causes headaches, scalp tenderness, jaw pain and vision problem

Question 12

What is myasthenia gravis?

Answer 12

A neuromuscular junction disease where antibodies block transmission from motor neurone to muscle
- Causes paralysis and weakness

The more you do, the weaker you get. So worse symptoms later in the day

Doesn’t cause sensory issues

Question 13

How is Myasthenia gravis diagnosed?

Answer 13

Look for autoantibodies

Question 14

What is Encephalitis?

Answer 14

Viral infection
Most commonly by Herpes simplex

Altered mental state
+ fever =CSF
+ Seizures =MRI
+ Focal signs =EEG

Question 15

Why is it important to diagnose encephalitis early?

Answer 15

It progresses quickly

The earlier the treatment, the better the outcome

Question 16

How do you diagnose Herpes simplex encephalitis?

Answer 16

Do a PCR of herpes

Question 17

How is encephalitis treated?

Answer 17

Treat the cause

Herpes: IV acyclovir

Question 18

What is Bell’s palsy?

Answer 18

1 sided facial weakness
Affects the facial nerve (CN7)

Eye-opening is spared because those nerves are not the facial nerve

Treat with steroids +/- acyclovir

Question 19

What is Uhthoff’s phenomenon?

Answer 19

Worsening of MS neurological symptoms on exercise/in warm environments (e.g. in a bath)

Lasts <24hours

Question 20

What is Lhermitte’s phenomenon?

Answer 20

Lightning-shock pain down the spine on flexion of the neck secondary to cervical cord plaque formation

Question 21

What are the symptoms of the CNS being affected by MS?

Answer 21

Motor:
Loss of power
Spasticity

Sensory:
Increasing sensitivity to pain
Tingling
Burning
Paraesthesia

Cerebellar:
Loss of balance
Diplopia
Dysarthria
Tremor
Fatigue

Depression/labile mood

Question 22

What are the symptoms of the ophthalmic system being affected by MS?

Answer 22

Nystagmus

Optic neuritis (pain on movement, visual field defect, loss of colour vision – particularly red)

Diplopia – internuclear ophthalmoplegia (INO)

Question 23

What are the symptoms of the Otolaryngeal system being affected by MS?

Answer 23

Dysphagia
Slurring/stuttering speech

Question 24

What are the symptoms of the muscular system being affected by MS?

Answer 24

Weakness
Cramping
Spasm/contractures

Question 25

What are the symptoms of the urinary system being affected by MS?

Answer 25

Urinary frequency
Incontinence
Retention

Question 26

What are the symptoms of the GI system being affected by MS?

Answer 26

Constipation or diarrhoea

Question 27

Which areas are important to cover in a history of MS?

Answer 27

• Past medical history (such as any history of focal neurologic deficit, or other autoimmune diseases)
• Family history of MS/other autoimmune diseases
• Smoking status
• Diet
• Impact on activities of daily living
• Driving status
• Falls risk assessment

Question 28

What are the examination findings of MS?

Answer 28

CN1: Optic neuritis: fundoscopy may reveal a blurry optic disc, Nystagmus
CN5: Facial paraesthesia
CN7: Forehead sparing facial weakness
CN8: Loss of balance/hearing
CN9/10/12: Loss of motor function of tongue/ pharynx causing speech and swallowing issues
CN11: LOF of sternocleidomastoid and trapezius causing neck weakness and hypotonia

Question 29

What are some lab tests done for MS?

Answer 29

Done to rule out other causes
- FBC (infection)
- CRP (marker of inflammatory process infective/autoimmune)
- LFT: ( rule out hepatic pathology)
- U&E’s: (electrolyte disturbances)
- Ca2+ and angiotensin converting enzyme: rule out sarcoidosis
- Thyroid function
- B12: rule out B12 peripheral neuropathy
- HIV serology

Question 30

What is the McDonald criteria?

Answer 30

The clinical, radiological and biochemical findings which must be met to make a diagnosis of MS

Question 31

What are the 4 subtypes of GBS?

Answer 31

1. Acute inflammatory demyelinating polyneuropathy (AIDP): most common in western Europe and north America. Primarily affecting the myelin sheath of affected nerves
2. Acute motor axonal neuropathy (AMAN): More common in Asia. Primarily damages the axons of motor neurons specifically. This results in a purely motor presentation.
3. Acute motor sensory axonal neuropathy (AMSAN): affecting motor and sensory neurons. Associated with a poorer rate of recovery.
4. Miller-Fisher syndrome: a form of GBS defined by antibodies to the GQIb ganglioside, typically associated with a triad of ophthalmoplegia, ataxia, and areflexia. No treatment is required