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Neurology= Clinical Medicine > MS > Flashcards

MS Flashcards

1
Q

Definition of MS

A

is a CNS inflammatory disease of largely white matter disseminated over space (the CNS) and time (episodic / remitting / recurring.)

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2
Q

What is MS Characterized by?

A

by relapsing and remitting, or progressive , neurologic deficits in multiple areas of the CNS over time

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3
Q

Epidemiology of MS (5)

A

Age at onset= 15 to 45 years
Gender= 70% women
Geography= Prevalence increases with latitude
Incidence= 8,500 - 10,000 new cases per year
US prevalence= 400,000 (1/1000)

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4
Q

Epidemiology based on Family (3)

A

30 % assoc in identical twins
5% assoc in first degree relatives
Increased chance of disease if patient spent the 1st 15 yrs of there life in northern latitudes

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5
Q

4 types of MS

A

Relapsing Remitting (RRMS) most common

Secondary Progressive (SPMS) occurs after 5-10 yrs in many patients with continued worsening but no clear exacerbations

Primary Progressive (PPMS)

Progressive –Relapsing (PRMS) least common

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6
Q

Likely locations of plaques associated with MS?

A

Likely locations of plaques are optic nerve, spinal cord, brainstem, juxtacortical and corpus callosum

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7
Q

Relapsing/Remitting MS

A

Episodes of acute worsening with recovery and a stable course between relapses

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8
Q

Secondary Progressive MS

A

Gradual neurologic deterioration with or without superimposed acute relapses in a pt who previously had RRMS

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9
Q

Primary Progressive MS

A

Gradual nearly continuous neurologic deteriorations from the onset of symptoms

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10
Q

Clinical Presentation of MS (5)

A

Weakness in the limbs may appear as loss of speed, dexterity, fatigue or gait troubles
Exercise induced weakness is characteristic of MS
diplopia
optic neuritis
hyperreflexia

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11
Q

Internuclear ophthalmoplegia (INO) (4)

A

coordination of eye movements requires a tract called the medial longitudinal fasciculus (MLF)
Lesions of the MLF create an ipsilateral adducting deficit
The contralateral eye has an abducting nystagmus
loss of central vision in a young person

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12
Q

Sensory Symptoms of MS (7)

A

paresthesias, hypesthesia, pain (esp hemibody numbness: ½ face, arm leg)
Ataxia
Cognitive dysfunction: memory issues, slower processing
Depression
Sexual Dysfunction
Vertigo

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13
Q

Hypesthesia

A

decreased sensation

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14
Q

Allodynia

A

pain on touch (RSD)

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15
Q

Hyperpathia

A

abnormally high subjective response to pain

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16
Q

Paresthesia

A

burning, itching, tingling without apparent cause

Not evoked by touch

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17
Q

How does a pt present with optic neuritis? (7)

A
  1. Decrease Visual Acuity – Pt may describe dimming of vision.
  2. Painful presentation, about 80%
  3. If inflammation at head of optic nerve, there will be a blurring of the boarder of the optic nerve.
  4. . Color (red) desaturation: picked up with red object testing covering each eye in turn. Cross 5. Cover Test, or use Ishihara plates
  5. Rarely bilateral
  6. Only 20% of Optic Neuritis will become MS
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18
Q

Retrobulbar Neuritis

A

If inflammation is far behind optic nerve head the nerve will appear normal

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19
Q

Treat optic neuritis by?

A

IV steroids

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20
Q

Genitourinary symptoms in MS (6)

A

Urinary retention
Urgency
Frequency
Can lead to chronic retention  self cath, suprapubic cath
UTI’s are a problem, pts develop sepsis
Rates of male impotence in MS is about 30%

21
Q

Lhermitte’s Phenomenon (2)

A

Shock-like sensation traveling down the spine with neck flexion
Pathophysiology: Mechanical stimulation of demyelinated axons can generate action potentials.

22
Q

Uhthoff’s Phenomenon (2)

A

Classically described as a decrease in visual acuity with a rise in body temperature
Pathophysiology: ‘warmth” activates the Na+/K+ pump

23
Q

Syndromes strongly associated with MS?

Under 40 and Over 40

A 
In Young Patients (Under 40) 
Bilateral trigeminal neuralgia
Acute optic neuritis 
Acute urinary retention or incontinence
Impotence in males
Internuclear Ophthalmoplegia
Bands of numbness or paresthesias

In Older Patients (Over 40)
Progressive painless spastic paraparesis
Abnormal gait
Bladder dysfunction

24
Q

When we can make a diagnosis of MS

A

New signs and symptoms need to last for at least 24 hrs to be considered a new attack
If we count objective lesions as evidence of an attack (hyperreflexia/ataxia/blindness etc..)and symptoms without physical evidence of an attack (numbness, cognitive loss etc..) There should be 2 attacks to make the diagnosis

25
Q

If there are not 2 attacks What Additional evidence is necessary?

A

Spinal fluid abnormalities (high cell WBC -high protein-oligoclonal bands (antibodies to a variety of antigens) IgG index (another antibody test )
MRI (the gold standard) showing new lesions which in the first 8 weeks enhance with and without Gadolinium (gad) This dye shows breaks in the blood brain barrier=enhancement

26
Q

characteristic presentations (5) which are likely to be associated with MS?

A
  1. optic neuritis
  2. brainstem syndrome
  3. Cerebellar syndrome
  4. spinal cord syndrome
  5. bilateral trigeminal neuralgia
27
Q

the typical example of Brainstem Syndrome?

A

Intranuclear ophthalmoplegia (INO) in which there is unilateral adduction loss and contra lateral abducting nystagmus

28
Q

Cerebellar Syndrome symptoms

A

unilateral or truncal ataxia (loss of coordination: heel/shin, finger to nose)

29
Q

Spinal cord syndrome symptom

A

unilateral or bilateral loss of pyramidal tract function (weakness and spasticity later) and or sensory dysfunction (commonly a sensory level on the trunk)

30
Q

What are some Ddx for MS? (5)

A
  1. Transverse Myelitis
  2. Devics Disease
  3. Optic Neuritis
  4. B12 Deficiency
  5. Seizures
  6. SLE
  7. Meningitis
31
Q

9 Lab Tests to Perform for MS

A 
B12 -& Methylmalonic acid high is abnl
ANA, RF
Lyme
Angiotensin converting enzyme (ACE)    (sarcoid)
TSH, T4
SSA, SSB (Sjogren)
RPR
ESR and CRP
Vitamin D level
32
Q

Importance of doing an MRI? (6)

A 
Monitoring treatment effect
Diagnosis
CIS
CDMS (clinically definite)
Standardized criteria
Predicting disability
33
Q

MS Symptomatic Treatment (3)

A

Physical and emotional support
Pharmacologic and therapy to address spasticity
PT for gait issues

34
Q

MS Treatment— Meds

A

Anti-inflammatory therapy (IV Steroids)= methylprednisolone— acute tx
Disease Modifying Therapy (DMT)- Decrease Relapses and Delay Disability—chronic tx
Immunomodulating drugs (i.e.. Betaseron)
Immunosuppresive agents

35
Q

Standard Platform Drugs ABCR for MS

A

A= Avonex IM injection weekly interferon Beta type 1-A
B=Betaseron Sub Q injection alt day interferon Beta type 1-B
C=Copaxone = Glatiramir acetate SubQ injection daily not a interferon
R=Rebif Sub Q injection alt day interferon Beta type 1-A

36
Q

What are the 3 new oral drugs for MS

A

Gilenya
Ticfedera
Abagio

37
Q

Abagio

A

Dimethyl fumerate

GI side effects are common

38
Q

Ticfedera

A

= Teriflunomide
Immunosuppressor
Contraindicated in pregnancy

39
Q

Gilenya

A

= Fingolimod
Contraindications: Heart block/ Macular eye disease/ Iritis Concerns: Asthma/Diabetes
MUST be immune to varicella (check titer)

40
Q

Relapse/ Exacerbation of MS (3)

A

Focal disturbance of function >24 hr
Occur about once a year in untreated patients
Always look for concurrent infection to R/O pseudo-exacerbation

41
Q

Adherence of Medication for MS patients?

A

Medication for chronic illness is only taken by 50-60% of patients as prescribed.
After 6 months, between 9-27% of MS patients have discontinued therapy.

42
Q

How do we measure the MS? (3)

A

cognitive dysfunction
lesion load
sustained disability

43
Q

Fatigue Scale (9)

A
  1. My motivation is lower when I am fatigued.
  2. Exercise brings on my fatigue.
  3. I am easily fatigued.
  4. Fatigue interferes with my physical functioning.
  5. Fatigue causes frequent problems for me.
  6. My fatigue prevents sustained physical functioning.
  7. Fatigue interferes with carrying out certain duties and
    responsibilities.
  8. Fatigue is among my three most disabling symptoms.
  9. Fatigue interferes with my work, family, or social life.
44
Q

Treatment options for managing fatigue?

A 
Exercise, PT, OT (energy conservation)
Amantadine (dopamine positive effects)
Modafinil (Provigil)
Stimulants (Amphetamines)
Anti-depressants (SSRI, Tricyclics, Effexor, Welbutrin)
45
Q

mental health and MS (3)

A

suicide
depression
functional status

46
Q

3 triggers for pseudoexacerbation?

A

infection
poor inadequate sleep
systemic illness

47
Q

Acute MS treatment

A

Initial options include IV steroids (one gram methylprednisolone daily for 5 days)
Complications
Acutely: include elevated sugar, mood changes
Chronically: peptic ulcers, bleeding, osteopenia, cataracts, infections, wt. gain, avascular necrosis
May be repeated in one month as a one day dose (monthly pulse steroids)

48
Q

Why Choose Tysabri over Gilenya?

A

Because Gilenya has precautions with use in Diabetes

Pt noncompliant with alt day injections and elects once a month infusion with few side effects

49
Q

Identification, Causation, Alleviation, and Prevention (ICAP) of symptoms in patients with MS

A

Identify the symptoms that arise during various stages of the disease
Symptoms result in disability and have a negative effect on the QOL
Early symptomatic intervention may mitigate risks of later morbidity
Examples – cognitive impairment, fatigue, sexual dysfunction, bladder and bowel issues
Causation – result of disease itself or a secondary consequence
Patients with MS often blame all of their symptoms on MS

Neurology= Clinical Medicine (6 decks)

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