Multiple sclerosis Flashcards
What is MS?
- Idiopathic inflammatory demyelinating disease of the CNS
* Acute episodes of inflammation are associated with focal neurological deficits
Describe the subtypes of MS
- Relapsing remitting MS - unpredictable attacks which may or may not leave permanent deficits followed by periods of remission
- Primary progressive MS - steady increase in disability without attacks
- Secondary progressive Ms - initial relapsing remitting MS that suddenly beings to have decline without periods of remission
- Benign MS
What are the syndromes that may develop into MS?
- Optic neuritis
- transverse myelitis (spinal cord)
- Radiologically isolated syndromes/ clinically isolate syndromes
Describe optic neuritis
- Painful visual loss that comes on over a few days in one eye
- May resolve after a few weeks
- Myelin of optic nerve becomes damaged
- Red desaturation
Describe transverse myelitis
- Inflammation of the spinal cord
- weakness
- Sensory loss below the level of inflammation
- Incontinence can be the only symptom
What are clinically isolated syndromes in the context of MS?
- Single episode of neurological disability due to focal CNS inflammation
- Can include optic neuritis and transverse myelitis or trigeminal neuralgia or hand weakness
- May be a first attack of MS
- can also happen after an infection and not be related to MS
When is MS diagnosed?
When there is evidence of 2 or more episodes of demyelination disseminated in space and time
What things are thought to factor into getting MS?
- Genetic factors
- Sunlight/vitamin D
- Viral trigger - possibly EBV
- Multifactorial - smoking
When should you suspect MS?
•Neurological symptoms that develop over a few days
•History of transient neurological symptoms that have lasted for more than 24 hours and spontaneously resolve
•’Hidden relapse’
- optic neuritis/visual disruption
- bells palsy
- labyrinthitis
- sensory symptoms
- bladder symptoms in young man or women without children
What are the central symptoms of MS?
- Fatigue
- Cognitive impairment
- Depression
- Unstable mood
What are the musculoskeletal symptoms of MS?
- Weakness
- Ataxia
- Spasm
What are the bowel symptoms of MS?
- Incontinence
* Diarrhoea or constipation
What are the urinary symptoms of MS?
- Incontinence
* Frequency
What symptoms/signs would make you think that it is something else other than MS?
- Sudden onset (think stroke)
- Peripheral signs- areflexia, glove and stocking distribution, muscle wasting, fasciculations
- Major cognitive involvement
- Reduced level of consciousness
- Prominent seizure
- Pyrexia/evidence of infection
- Normal MRI scan
What is radiologically isolated syndrome?
- MRI scan performed in a patient who doesn’t have signs or symptoms of MS
- Incidental finding that looks like MS
- May develop into MS but also may not
- Can cause unnecessary distress for patient
How should you investigated suspected MS?
- MRI brain and cervical spine with gadolinium contrast
- Lumbar puncture
- Bloods to exclude other conditions
- Visual evoked potentials
- Chest Xray to exclude sarcoidosis
Describe the use of MRI to diagnose MS
- Evidence of demyelination in 2 regions (e.g. periventricular and spinal cord) can indicated dissemination in space
- If enhancing and non-enhancing areas of demyelination are seen this can indicate dissemination in time (suggestions that damage has occurred more than once)
Explain lumbar puncture in MS
- CSF oligoclonal bands (immune proteins in the spinal fluid and not in blood- immune system active behind BBB) - can also be seen in other conditions
- CSF cell counts to exclude mimics
- CSF glucose
- CSF proteins
Specifically what bloods should be done in suspected MS and why?
- B12/folate to look for deficiency
- Serum ACE
- Lyme serology
- ESR/CRP
- ANA/ANCA/Rheumatoid factor
- Aquaporin-4 antibodies (neuromyelitis optica)
What is the role of visual evoke potentials?
•Measure the conduction of nerve signals in the optic nerve to look for subclinical optic neuritis
•Conduction will be slower if a patient has had optic neuritis in the past
What is the difference between relapse and pseudo-relapse in MS?
- A relapse usually involves a new neurological deficit that lasts for more than 24 hours in the absence of pyrexia or infection
- A pseudo-relapse is the reemergence of previous neurological symptoms or signs related to an old area of demyelination in the context of heat or infection
- When body temperature increases, conduction slows leading to dysfunction
Explain treatment of relapse of MS
- Not all relapses need treatment and should fully discuss the side effects of high dose steroid with patients
- Steroids may speed up recovery from relapse with no effect on the progression of the disease
- If appropriate, physiotherapy +/- occupational therapy
- Sometimes in RRMS there may be a plan to organise MRI with contrast to look for active disease and change treatment
When should steroids not be given to a patient experiencing a relapse of MS?
Steroids shouldn’t be given if there is any evidence of infection
What is the pharmacological regime for relapse of MS
- 1g of IV methylprednisolone for 3 days or 500mg of oral methylprednisolone for 5 days
- PPI for gastroprotection (e.g. omeprazole)
- Ideally prescribe at 9am to avoid sleep disruption
What are the disease modifying drugs for RRMS?
- Aletuzumab
- Natalizumab
- Anti CD20: ocrelizumab, rituximab, ofatmumab
- Fingolimod
- Dimethyl fumarate
- Cladribine
What type of stem cell transplant could be considered in severe RRMS?
Autologous haemopoetic stem cell transplant
What is the treatment for PPMS?
Ocrelizumab
What is the treatment for SPMS?
Siponimod
Describe the use of ocrelizumab
- First licensed treatment for PPMS
- Slows disability progression in patients with recent active inflammation on scans
- Patient must be walking to benefit
- Increased risk of infection/severe COVID
Describe the use of siponimod
- First licensed treatment for SPMS
- For use in people who have active inflammation in their brain scan s
- Patients must be walking to benefit
