MS/MG Flashcards
What is Multiple Sclerosis
Autoimmune CNS disorder causing multiple foci of demyelination
What are the major mechanisms of MS
Inflammation
Demyelination
Axon damage
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
Who is MS more prevalent is
white women 20-40
Disease of latitudes (NO eskimos)
What is the presumed etiology behind MS
genetically predisposed + Immunodeficient + Environmental factor = first exacerbation
What nutritional deficiency is linked to MS
Vitamin D
Who is genetically predisposed to MS
if your sibling has MS, esp. identical twins HLA alleles (AI d/o): HLA DR2, HLA DR4
MS attacks must be
separated in time and space
last >24 hours
+/- progression (even w/o exacerbation)
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
What is optic neuritis
Loss of vision and pain with movement in affected eye, due to inflamed optic nerve
*Phosphenes (seeing stars)
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
What is a common presenting symptom of Acute Transverse Myelitis
L’Hermitte’s sign; flexing the neck forward sends shooting pain down the spine
What is the MC Sx causing unemployment in MS patients
Fatigue (physical and mental)
-R/o vitamin deficiency, anemia, and thyroid disease
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
What cognitive dysfunction occurs in MS
comprehension (use of speech) attention memory planning problem solving executive function abstract reasoning
What types of pain are associated with MS
Primary (burning sensation)
Secondary (muscular pain d/t effects of MS)
What urinary Sx occur in MS
failure to store, empty, or both
Frequency
urgency
incontinence
MC bowel complaint with MS is
Constipation
How is the thyroid associated with bowel complaints
Hypothyroid= constipation Hyperthyroid= diarrhea
What is iternuclear ophthalmoplegia
When you ask the patient to look L or R, but the affected eye cant adduct
This causes diplopia
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)
What are signs of spasticity
Bent wrist
Closed fist
Flexed elbow
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
