MS/MG Flashcards by Nayla Mansoor

What is Multiple Sclerosis

Autoimmune CNS disorder causing multiple foci of demyelination

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What are the major mechanisms of MS

Inflammation
Demyelination
Axon damage

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What regions of the brain are involved in MS

In White matter, myelinated and unmyelinated axons carry messages to grey matter
Grey matter has the neuron cell bodies and dendrites

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Who is MS more prevalent is

white women 20-40

Disease of latitudes (NO eskimos)

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What is the presumed etiology behind MS

genetically predisposed + Immunodeficient + Environmental factor = first exacerbation

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What nutritional deficiency is linked to MS

Vitamin D

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Who is genetically predisposed to MS

if your sibling has MS, esp. identical twins 
HLA alleles (AI d/o): HLA DR2, HLA DR4

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MS attacks must be

separated in time and space
last >24 hours
+/- progression (even w/o exacerbation)

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Classic MS symptoms include

*Optic Neuritis 
Paresthesias, diplopia, fatigue, pain, depression
Cerebellar Sx (ataxia, disequilibrium) 
Spinal cord motor Sx (muscle fatigue) 
autonomic dysfunction (bladder/bowel/sex) 
Cognitive difficulties (grey matter) 
Heat intolerance 
Sx of partial acute transverse myelitis

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What is optic neuritis

Loss of vision and pain with movement in affected eye, due to inflamed optic nerve
*Phosphenes (seeing stars)

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What is acute transverse myelitis

acute partial loss of motor, sensory, autonomic, and reflex (sphincter function below lesion) due to inflammaiton of spinal cord
-Consider mechanical compression before MS

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What is a common presenting symptom of Acute Transverse Myelitis

L’Hermitte’s sign; flexing the neck forward sends shooting pain down the spine

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What is the MC Sx causing unemployment in MS patients

Fatigue (physical and mental)

-R/o vitamin deficiency, anemia, and thyroid disease

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What is “spasticity”

increased muscle tone and resistance to movement, mostly in posture muscles
Increase in muscle stiffness= you have to use more energy= fatigue

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What cognitive dysfunction occurs in MS

comprehension (use of speech) 
attention
memory
planning
problem solving
executive function
abstract reasoning

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What types of pain are associated with MS

Primary (burning sensation)

Secondary (muscular pain d/t effects of MS)

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What urinary Sx occur in MS

failure to store, empty, or both
Frequency
urgency
incontinence

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MC bowel complaint with MS is

Constipation

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How is the thyroid associated with bowel complaints

Hypothyroid= constipation
Hyperthyroid= diarrhea

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What is iternuclear ophthalmoplegia

When you ask the patient to look L or R, but the affected eye cant adduct
This causes diplopia

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What are some key PE areas to hit for MS

MMSE 
CN (VA, VF, EOM)- paresthesias and nystagmus  
Reflexes (asymmetry, babinski) 
Motor
Sensory
Gait (antalgic)

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What are signs of spasticity

Bent wrist
Closed fist
Flexed elbow

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What relieves spasticity

Baclofen (muscle relaxer)

Important MS Ddx include

Spinal cord neoplasm 
Encephaloyelitis
Sarcoidosis 
Transverse myelitis
B12 deficiency (spinal cord degeneration)

What imaging should you get for MS

Brain/Spinal cord MRI w/ contrast

Other diagnostic tests for MS are

``` labs CSF Evoked potentials +/- Lyme serology, rheumatologic labs (ANA, RPR, ESR) B12, TSH, HIV, CXR ```

What would LP with (+) MS show

IgG (>0.7) and oligoclonal bands (>2)

What are the types of MS

PPMS (steady increase) SPMS (initial RRMS with sudden decline, no remission) PRMS (steady Increase w/ superimposed attacks) RRMS (unpredictable attacks)

Compare RRMS and PPMS outcomes

PPMS: 5 years, 50% will have cane RRMS: 15 years, 50% will have cane

What does the new MS criteria (McDonald) say

Dissemination in time (Sx 1+ months apart) | Dissemination in space (lesions in 2 diff. parts of CNS)

How do you treat acute MS exacerbations

corticosteroids (high dose IV methylprednisone)

What can you use to treat RRMS and SPMS

``` IFN-B (avonex, Rebif) Glatiramir acetate (daily injection) Fingolimod Natilizumab Dimethyl fumirase ```

What does the first dose of Fingolimod cause

bradycardia; do not give to patients with 2/3 degree AV block

When should you give Natilizumab or Dimethyl fumirase

Only in aggressive/resistant RRMS, because of the increased risk of PML

What meds treat fatigue in MS

Amantadine Adderall Modafinil

What meds treat cognitive changes in MS

Aricept, Namenda, Exelon patch

What meds treat depression in MS

SSRI | TCA

How do you treat bladder problems in MS

Bladder training | Anti-spastic meds (Vesicare, Detrol, Ditropan)

What meds can you use to treat constipation in MS

``` Miralax Metamucil Citruce Colace increase fiber ```

What is Myasthenia Gravis

Autoimmune disorder caused by antibody mediated block of neuromuscular transmission, causing skeletal muscle weakness Progressive over weeks to months

How does an autoimmune attack occur

Auto antibodies form against Nicotinic ACh receptors at NMJ of skeletal muscles

Who is MG more prevalent in

Men 60-70 | Women 30

What do we always try to prevent in MG

Myasthenic crisis (need for intubation)

How does MG present

painLESS specific muscle weakness affecting EOM, bulbar, or proximal limb muscles

What is the MC presenting symptom in MG

Ptosis/Diplopia

Other MG symptoms include

Dysphagia Slurred speech Difficulty chewing (NO liquid diet -->aspiration) face/neck extension/flexion weakness

What is the hallmark of MG

Muscles get weaker with repeat use (at end of day) and relieve with rest or ice therapy

What can trigger or worsen MG

``` warm weather Aminoglycosides in last 6-8 weeks (genta, tobra) Surgery Vaccinations Menses Incurrent illness Pregnancy or post-partum ```

What are common PE findings in MG

Facial muscle weakness (bilateral sagging) corners of mouth droop (Myasthenic snarl) cant whistle, suck, or blow

What must you assess for ASAP

Respiratory failure! this is URGENT

What is preferred MG diagnosis test

AChR antibody test

What can cause a false (+) AChR test

Thymoma SCC RA treated with penicillamine Lambert-Eaton Myasthenic syndrome

What diagnostic studies are done for MG

CXR (thymoma) MRI brain/orbit (IF strictly ocular Sx) EKG

What is the icepack test

put an ice pack over affected muscles (like eye lid) and Sx should improve- cold increases NM function

How do you manage MG

Acetylcholinesterase inhibitor Pyridostigmine for maintenance (or neostigmine) IVIG Plasmapheresis long term immunosuppression (Prednisone, azathioprine) thymectomy

What is the prognosis of MG

near normal life w/ current treatments- low mortality | Slightly worse if >40, short Hx of disease, or you have a thymoma

The only feared condition in MG is

Weakness in respiratory muscles