MS and other Inflammatory CNS Diseases Flashcards
What is MS?
An inflammatory demyelinating disorder of the CNS
MS is associated with plaques which are?
Disseminated in time and place
What is the female to male ratio in MS?
3:1
When does initial presentation in MS tend to occur?
30’s-40’s
What are the 4 main clinical courses of MS?
- Primary progressive.
- Progressive relapsing.
- Secondary progressive.
- Relapsing remitting.
Describe secondary progressive MS.
Is more insidious, involves a gradual worsening of symptoms.
Outline the main clinical features of MS.
- Pyramidal dysfunction.
- Optic neuritis.
- Sensory sx.
- Lower urinary tract dysfunction.
- Cerebellar and brain stem features.
- Cognitive impairment.
What are the signs and symptoms of pyramidal dysfunction?
Increased tone. (velocity dependent)
Spasticity.
Weakness.
- extensors of the upper limbs
- flexors of the lower limbs
What does optic neuritis present as?
Painful visual loss
How long does optic neuritis last for?
1-2 weeks
Most people with optic neuritis improve
TRUE
What sign may be present on examination of a patient with optic neuritis?
RAPD - relative afferent pupillary defect
What sensory symptoms might a patient with MS experience?
- Pain. (‘cross-wiring’ - instead of touch, you feel pain)
- Paraesthesia
- Dorsal column loss Proprioception + Vibration
- Numbness
- Trigeminal neuralgia
Outline the signs and symptoms that may occur as a result of cerebellar dysfunction in MS?
- Ataxia.
- Intention tremor.
- Nystagmus.
- Past pointing.
- Pendular reflexes (where reflexes continue after being elicited by tendon hammer).
- Dysdiadokinesis (problem with co-ordination of rapid movement).
- Dysarthria.
What are pendular reflexes?
When reflexes continue after being elicited by a tendon hammer
What may occur as a result of brain stem dysfunction?
diplopia and facial nerve palsy
Damage to which CN causes diplopia?
CN VI
Damage to which CN causes facial weakness?
CN VII
Imaging in MS….
Lesions tend to be bright on T2 weighted sequence
What area of the brain is affected in internuclear ophthalmoplegia?
Medial longitudinal fasiculus
What signs + symptoms does damage to the medial longitudinal fasiculus result in?
- Distortion of binocular vision.
- Failure of adduction – diplopia.
- Nystagmus in abducting eye.
- Lag.
What lower urinary tract signs + symptoms might a patient with MS experience?
- Frequency.
- Nocturia.
- Urgency.
- Urge incontinence.
- Retention.
Name a drug which helps with fatigue in MS patients.
Amatandine
or hyperbaric oxygen
Name a drug that is given for sleepiness in MS patients.
Modafinil
What are the key criteria for a diagnosis of MS to be made?
- At least 2 episodes suggestive of demyelination
* DISSEMINATION in TIME and PLACE
What investigations are done for a patient with suspected MS?
- MRI
- CSF
- Neurophysiology
- Blood tests
What blood tests are done in suspected MS?
Plasma viscosity, FBC, CRP Renal liver bone profile Auto anti body screen Borellia, HIV, syphilis serology B12 and folate
What should the results for the blood tests be in MS?
NORMAL - you are basically trying to prove that it is nothing else causing the symptoms
A lumbar puncture in a patient with MS is _______
ABNORMAL
90% of patients with MS have abnormal LP’s
TRUE
What would be seen in an LP of a patient with MS?
Unmatched.
Oligoclonal bands present
Oligoclonal bands must be present for a patient to have MS
FALSE - even if none are detected, the patient could still have MS
How is a MILD acute exacerbation of MS managed?
Symptomatic treatment
How is a MODERATE acute exacerbation of MS managed?
Oral steroids
How is a SEVERE acute exacerbation of MS managed?
Admit + IV steroids
What steroid is used?
Prednisolone
What are the symptoms of pyramidal dysfunction?
Weakness and spasticity
What are the 3 main treatments for pyramidal dysfunction?
1 – Physiotherapy
2 – Occupational therapy
3 – Anti-spasmodic agent
What are the treatment options for spasticity in MS?
- Physiotherapy
- Oral medication - BACLOFEN, TIZANIDINE.
- Botulinum toxin
- Intrathecal baclofen/phenol
When is intrathecal baclofen/phenol used?
End of life care - relief of symptoms
- this irreversibly kills off the nerves
What sensory symptoms are associated with MS?
Pain
Paraesthesia
Numbness
Trigeminal neuralgia
What are the treatment options for the sensory symptoms caused by MS? i.e
- Pain
- Paraesthesia
- Numbness
- Trigeminal neuralgia
Anti-convulsant - gabapentin Anti-depressant - amitriptyline TENS machine Acupuncture Lignocaine infusion
How can the urinary tract be affected in MS?
Increased tone at bladder neck
Detrusor hypersensitivity
Detruser sphyncteric dyssenergia (sphincter problem)
What are the signs that the LUT is affected in MS?
Frequency and nocturia
Urgency
Urge incontinence
Retention
What are the treatment options for LUT dysfunction in MS?
Bladder drill
Anti-cholinergics ie. oxybutynin
Desmopressin
Catheterisation
Outline the treatment options for fatigue caused by MS.
Amantadine
Modafinil if sleepy
Hyperbaric oxygen
There are various disease modifying therapies used in MS. Outline the 1st, 2nd and 3rd options.
1st - interferon beta, tecfedira, cop axone
2nd - monoclonal antibody, fingolimoid
3rd - mitoxantrone
How is interferon beta and cop axone administered?
Injection
What is the effect of the 1st line disease modifying therapy?
- decrease relapse rate by 1/3rd.
- decrease severity of relapses by 50%.
How is tecfidera administered?
Oral
What is tecfidera the 1st line treatment for?
RR MS (relapsing remitting MS)
What drug Lowers white cell count so regular blood tests are required?
TECFIDERA
What route is fingolimoid given via?
Oral
What is fingolimoid?
A sphingosine 1-phosphate (S1P) modulator
What line is fingolimoid?
2nd
Fingolimoid results in a __% reduction rate in relapses
50%
Name 3 monoclonal antibodies.
Tysabri.
Lemtrada.
Zymbata
Who gets monoclonal antibodies?
Highly active relapsing-remitting MS (RRMS) patients:
- those with rapidly evolving severe RRMS.
- those with high disease activity, despite tx with an interferon.
