Multiple Sclerosis Flashcards
Define multiple sclerosis
chronic and progressive autoimmune disorder characterised by demyelination in the central nervous system (CNS)
What structures comprise the CNS
Brain
Brainstem
Spinal cord
What process causes the activatin of the immune cells against the myelin in the CNS leading to demyelination
Inflammatory
What is the hallmark of MS
Demyelination
multiple sclerosis is an autoimmune disorder in which the immune cells act against what in the CNS
Myelin leading to demyelination
What is the typical age of diagnosis of multiple sclerosis
20-40 years old
Multiple sclerosis is more commonly seen in what gender?
Females
Name a gene that has been linked as a risk factor of Multiple sclerosis
HLA DRB1
Name an infection that has been linked to the development of Multiple sclerosis
Epstein-Barr virus (EBV)
Name some of the risk factors multiple sclerosis
Age - commonly diagnosed in 20-40
Gender - more common in females
Genetic component
Geographic latitude: increase incidence in the greater distance north or south
Sunlight exposure
Epstein–Barr virus (EBV) e.g. glandular fever
Low vitamin D
Smoking
Obesity
Name a protective factor of multiple sclerosis
Symptoms tend to improve in pregnancy and in the postpartum period.
Name the cell that produces myelin in the peripheral nervous system
Schwann cells
Name the cell that produces myelin in the central nervous system
Oligodendrocytes
Multiple sclerosis typically affects the:
a) CNS
b) PNS
c) Both
a) CNS
What causes the damage to the myelin (demyelination) in multiple sclerosis
Inflammation and infiltration of immune cells around the myelin
Why do symptoms early in the disease resolve whilst in late multiple sclerosis they dont?
- In early disease, re-myelination can occur and symptoms can resolve
- In the later stages, re-myelination is incomplete and the symptoms gradually become more permanent.
Define clinical isolated syndrome
- Referred as the first episode of suspected MS
- MS cannot be diagnosed on one episode as the lesions have not been “disseminated in time and space”
Why cant multiple sclerosis be diagnosed on one episode
lesions have to “disseminated in time and space”
i.e. the symptoms change over time (as different nerves are affects)
Multiple sclerosis can be categorised depending on the disease patterns.
Name the 3 types of MS disease patterns
Relapsing-remitting
Primary progressive
Secondary progressive
What is the most common disease pattern for multiple sclerosis
Relapsing-remitting (90% of cases)
Describe the characteristics of the relapsing-remitting multiple sclerosis pattern
Characterised by episodes of disease and neurological symptoms followed by recovery (remissions)
Describe the characteritics of the secondary progressive multiple sclerosis disease pattern
Characterised by a relapsing-remitting phenotype initially but eventually there is progressive worsening of symptoms with incomplete remissions
Disease course changes with gradual, sustained worsening in neurological function.
Relapses may still occur but without remission.
What percetange of patients with relapse-remitting multiple sclerosis will develop secondary progressive pattern within 15 years since onset
50% of patients with relapse-remitting phenotype will develop secondary progressive pattern within 15 years of onset
Secondary progressive multiple sclerosis pattern has a close relationship with another disease pattern - in case over 50% of the other disease pattern ultimately develop secondary progressive pattern.
Name the other disease pattern
Remitting-remission multiple sclerosis
Describe the characteristics of the primary progressive multiple sclerosis disease progression
Characterised by worsening of disease and neurological symptoms from the onset of diagnosis
May have periods where disease is not active or non-progressive, however there is no relapses or remission
What multiple sclerosis disease pattern has:
Relapse without remission
Secondary progressive multiple sclerosis
What multiple sclerosis disease pattern has:
No Relapse and no remission
Primary progressive multiple sclerosis
What other disease pattern may patients with relapse-remittin develop as their disease progresses
Secondary progressive multiple sclerosis
Name this multiple sclerosis disease pattern
Secondary progressive multiple sclerosis
Name this multiple sclerosis disease pattern
Primary progressive multiple sclerosis
Name this multiple sclerosis disease pattern
Relapsing-remitting multiple sclerosis
Define the term: relapse period
refers to a period of new symptoms
Define the term: remission period
Remission follows a relapse, a period with no or few symptoms – the symptoms they experience at this stage is residual damage
How long will MS symptoms tend to last at first presentation
Symptoms tend to last days-weeks and then improve
Multiple sclerosis (MS) is multifocal and therefore there is large variability of symptoms – depends on the plaque location within the CNS.
Name the two most common clinical manifestations of MS
Optic neuritis
Lethargy
The clinical manifestations of multiple sclerosis is broadly grouped into 4 groups.
Name these groups
o Visual
o Motor and coordination
o Sensory and autonomic
o Cognitive and psychological
Optic neuritis involves the demyelination of what structure
the optic nerve
Optic neuritis involves the demyelination of the optic nerve.
What is the result of this?
Loss of vision in one eye
Sixth nerve palsy is a potential symptom of multiple sclerosis.
What two problems can this cause
Internuclear ophthalmoplegia
Conjugate lateral gaze disorder
Internuclear ophthalmoplegia can occur as a consequence of a sixth nerve palsy.
What are the clinical features of Internuclear ophthalmoplegia
blurry vision
Diplopia (double vision)
Conjugate lateral gaze disorder can occur as a consequence of a sixth nerve palsy.
Describe what is affected in patients with this disorder
The affected eye will not able abduct
i.e. when looking laterally in the direction of the affected eye, the unaffected eye will adduct (move towards the nose) but the affected eye will not abduct (move laterally)
Name some of the Motor and Co-ordination clinical manifestations of multiple sclerosis
Progressive paraparesis i.e. paralysis of both legs
Upper motor neurone signs (spasticity, reduced power, hyper-reflexia)
Ataxia – lack of muscle coordination
Name some of the sensory and autonomic clinical manifestations of multiple sclerosis
Paraesthesia i.e. pins and needles
Pain
Numbness
Uhthoff phenomenon – worsen of vision following rise in body temp.
Uhthoff phenomenon is a potential clinical manifestation of multiple sclerosis.
Describe the phenomenon
Worsen of vision following rise in body temp.
Multiple sclerosis can have what type of signs:
a) Upper motor signs
b) Lower motor signs
c) Both
d) Neither
a) Upper motor signs
Multiple sclerosis cannot be diagnosed on one episode as the lesion have to disseminated in time and space.
Diagnosis is based on at least two of the following criteria
Clinical history/examination
Imaging features (usually MRI)
Oligoclonal bands in CSF
What is the name of the diagnostic criteria for the diagnosis of MS based on MRI findings and clinical presentation
McDonald criteria
McDonald criteria is a diganostic criteria for the diagnosis of what condition
for the diagnosis of MS based on MRI findings and clinical presentation
What is the imaging modality that is useful for the diagnosis and surveillance of MS (to assess response to treatment)
MRI
What is the gold standard imaging modality for multiple sclerosis
MRI
MRI is the most useful imaging modality for multiple sclerosis.
What aspects of the multiple sclerosis is it useful for
- Diagnosis - can identify the demyelinating lesions
- Surveillance to assess response to treatment
Name the two hallmark features of multiple sclerosis on MRI
Plaques of demyelination
Eventual axonal loss
Lumbar puncture is important in investigating multiple sclerosis.
What are you trying to detect in the CSF
oligoclonal bands
What are oligoclonal bands and what do their presence indicate?
Oligoclonal bands are bands of immunoglobulins
They indicate the presence of an autoimmune response in the CNS
Oligoclonal bands are very sensitive for multiple sclerosis although they can also be found in other auto-immune and infectious conditions.
Give an example of another condition in which they are found in
Lyme disease, SLE.
Multiple sclerosis patients should be under the care of a multidisciplinary MS team. There is no cure for MS however the aim of management is three fold.
Name these 3 parts of the management of ms
Disease modification therapies
Treat acute relapses
symptomatic relief as symptoms develop.
What is the aim of management with disease modification therapies in multiple sclerosis
Aim to decrease the number of relapses and slow disease progression
Give an example of a disease modification therapies used in the management of multiple sclerosis
First-line injectables e.g. beta-interferon and glatiramer
New oral agents e.g. dimethyl fumarate, teriflunomide and fingolimod
Biologics e.g. natalizumab and alemtuzumab.
How are acute relapses of multiple sclerosis managed
- High dose steroids e.g., methylprednisolone
- 500mg orally daily for 5 days
- 1g intravenously daily for 3–5 days where oral treatment has failed previously or where relapses are severe
Why are steroids only used to treat acute relapse and not used in the long term management of multiple sclerosis
Steroids shorten the duration of a relapse but they do not alter the degree of recovery (i.e. whether a patient returns to baseline function)
A part of the management of multiple sclerosis is to provide symptomatic relief as symptoms develop.
Give an example of one which symptom and its management
Exercise to maintain activity and strength
Neuropathic pain can be managed with medication such as amitriptyline or gabapentin
