What are the risk factors for MS?
- Women>men
- Europeans
- Age: 20-40yrs
- 1st degree relative with MS
- Reduced vitamin D
What are the features of MS?
- Optic neuritis
- Cerebral
- Cerebellar
- Brainstem problems
- Spinal cord
- UMN signs
What is L’Hermitte’s sign?
Sudden electric shock like sensation radiating down and up the spinal column, provoked by flexion or extension of the neck
What is the typical history of MS?
Separate attacks of inflammation within the CNS at different times and in different places
o History of previous neurological symptoms
o Symptoms that evolve over more than 24 hrs and may persist over several days/weeks then improve
What are the different types of MS?
Relapse remitting (RRMS) o Attacks (relapses) with complete or partial recovery o No progression between attacks (remission)
Secondary progressive (SPMS) o Initial relapsing-remitting course followed by progression
Primary progressive (PPMS) o Progression from onset, no attacks
Progressive relapsing (PRMS) o Progression from onset with attacks
What investigations do you do?
- MRI brain/spinal cord with contrast
- Lumbar puncture
- Evoked potentials
- Gadolinium contrast
- Serum Vitamin B12
What could an MRI brain show?
- High signal T2 lesions
- Periventricular plaques
- Dawson fingers: hyperintense lesions perpendicular to corpus callosum
What could a lumbar puncture show?
Oligoclonal bands in CSF
How do you manage a MS relapse?
o High-dose steroids – IV methylprednisolone 1g daily 3 days/ PO methylprednisolone 0.5g 5 days
o PPI
What do you need to check before giving treatment for a MS relapse?
- Check there are no signs or symptoms of systemic infection
- FBC, renal function, random glucose and urine dipstick
CI: infection, poorly controlled diabetes or HTN
When would you give beta-interferon?
- RR-MS + 2 relapses in past 2yrs + able to walk 100m unaided
- SP-MS + 2 relapses in past 2yrs + able to walk 10m
What can alemtuzumab cause?
- Autoimmune thyroid disease,
- Immune thrombocytopenia
- Goodpasture syndrome
How do you manage neuropathic pain?
1st line: gabapentin, pregabalin, amitriptyline or duloxetine (GI SE)
o If not working, switch drug instead of adding one
How do you manage muscle spasticity?
1st line: Baclofen or gabapentin
How do you manage neuropathic bladder?
Oxybutynin
What inflammatory conditions can mimic MS?
- Anticardiolipin/Antiphospholipid antibody syndrome
- Devic’s syndrome (neuromyelitis optica)
- Neurosarcoidosis
- Sjogren’s syndrome
- Behcet’s syndrome
What questions would you ask in the history to exclude an inflammatory cause?
- Rashes
- Fever
- Arthropathy
- Uveitis
- Weight loss
- Respiratory difficulties
