Multiple Sclerosis Flashcards

1
Q

epidemiology

A

multifactorical cause → genetic background + environmental triggers
age of onset: 15-45 - about 6% is early onset → study early stages
gender bias: 5:1 female to male ratio
common in Northern Europeans - immigration
not Mendelian inheritance → genome wide studies showed implication in HLA-DRB1-15:01 gene; MHC; IL2RA/IL7RA

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2
Q

risk factors

A

insufficient vitamin D
infections (EBV)
smoking
salt

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3
Q

Expanded Disability Status Scale

A

neurological exam to track progression
motor changes (not cognitive/sensory)
determine extent of disability
>6 requires assistance

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4
Q

clinical picture

A
  1. relapse-remitting: inflammation is focal with flares - spikes last weeks to months then return to baseline; possible residual symptoms between spikes → recovery decreases as patient ages (decline in repair systems)
  2. secondary progression: independent of focal inflammation; less fluctuations; increase in symptoms
    variety of symptoms correspond to location of lesions in brain + spinal cord
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5
Q

Pathology

A

demyelination: immune system attacks myelin of cells and causes inflammation and damage → sclerotic lesions are ventricular (around ventricles) - primarily in white matter (shown with staining and MRI)
can lead to axonal degeneration (atrophy + death of neurons) → attempt at remyelination is often incomplete or complete axon transection → transection of fibres of corticospinal tract
decreased axonal density in plaques as a result of injury and inflammation → ventricles, optic nerves + tracts, corpus callosum

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6
Q

Experimental Autoimmune Encephalomyelitis

A

EAE can be produced in animals by myelin specific T cells
induced in animal model to understand pathogenesis
external immunization: inject myelin basic protein into mice → trigger immune response to produce disease-primed lymphocytes (B cells and T cells) through antigen presentation

injection of MBP-specific TH1 cells (lymphocytes) into tail vein of healthy mouse induces disease - the cells are primed to respond to disease = attack myelin in CNS and induce inflammatory response with similar pathology to MS

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7
Q

models of molecular mimicry

A

antigen presentation of virus (similar to endogenous MBP) to naive T cells causes expansion of virus-specific T cells and the expansion of cross reactive MBP-specific T cells → target endogenous molecule similar to antigen

both T cells will enter CNS, recognize MBP, and initiate inflammatory damage

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8
Q

immune response

A

recognition and presentation of foreign antigen → activation and proliferation of naive T helper 0 cells into T helper 1 and 2 cells
cell-mediated T-cell responses derived from T helper 1 cells; antibody-mediated responses derived from T helper 2 cells → activation of B cells

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9
Q

T cell differentiation

A

IL-2 and IFNy → TH1 cells
IL-23 → TH17 cells
IL-4 → TH2 cells
TGFb and IL-2 → Treg

differentiation occurs in the periphery → cross BBB into CNS - reactivated

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10
Q

T lymphocytes

A

reactivation in CNS
TH1 and TH17 secrete cytokines that activate microglia/astrocytes + macrophages → APC function + ROS/RNS production

inhibition of T eff cells (+ inflammatory cells) by anti-inflammatory cells → Treg and Breg - decrease pro-inflammatory

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11
Q

B lymphocytes

A

different roles: antigen presentation, cytokine activation, activating T cells, antibody production
Breg → limit pro-inflammatory

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12
Q

pathogenesis

A

microglia activation
inflammation
ionic imbalance + increased Na+ levels
demyelination
neuro-axonal degeneration
glutamate excitotoxicity
mitochondrial damage → energy failure
astrocyte activation

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13
Q

imaging to measure damage

A

MRI - inflammation
MRS - spectroscopy → injury demyelination
PET scan - microglial inflammation

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14
Q

acute MS lesions

A

axonal transection
interrupts flow of cell → causes swelling

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15
Q

immune-independent neurodegeneration

A
  • mtDNA mutations + mitochondrial injury → ROS/RNS
    (ROS/RNS can also cause mitochondrial injury)
  • demyelination → Fe3+ → oxidative stress
  • glutamate excitotoxicity → Ca2+ influx; ionic imbalance
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16
Q

progression of MS

A

axon loss correlates with progression but over time becomes immune-independent

brain atrophy - significant degeneration of white + grey matter; enlargement of ventricles

17
Q

symptoms

A

clinical manifestations: ocular (blurred vision; diplopia), cerebellar (ataxia; vertigo; nystagmus), autonomic (urinary incontinence; sexual disorders), motor (pain; decreased strength; muscle spasms)

18
Q

motor reflex arc

A

lesion that transects reticulospinal/pyramidal tract causes constant muscle contraction → spasticity

removes inhibition of motor neurons

19
Q

fatigue

A

feeling of physical tiredness and lack of energy distinct from sadness or weakness

20
Q

bladder dysfunction

A

overactivity or inefficiency
detrusor-sphincter dyssynergia: co-contraction of bladder and urethral spincter - should be coordinated

21
Q

persistent neurogenic pain

A

burning sensation of limbs/trunk
disruption of spinothalamic pathway

22
Q

paroxysmal neurogenic pain

A

trigeminal neuralgia
episodes of excruciating facial pain

23
Q

immunotherapies

A

interferon-b; GA → increase anti-inflammatory state
immunomodulators
traffickers
immuno-depleters
chemotherapies
stem cell transplant

24
Q

interferon-B

A

acts through interferonB receptor to inhibit antigen presentation + T cell activation → decreases pro-inflammatory TH1 cytokines
increases anti-inflammatory state
injectable

25
Q

Glatiramer Acetate

A

presented as an antigen → generates GA-specific T cells - TH2 cells
increases anti-inflammatory state
injectable

26
Q

immunomodulators

A

reduce immune cell numbers, alter function, block access to CNS
ex. DMF targets Nrf2
- protective response against neurotoxic insult → increases cell tissue and cytoprotection
- anti-inflammatory response → decreases inflammation and tissue damage

27
Q

traffickers

A

stop cells from entering CNS → decrease inflammatory state of immune cells
consequence - pathogenic cells proliferate in absence of immune cells

ex. NTZ: monoclonal antibody acts on VLA-4 to block crossing of BBB
ex. FINGO: targets S1P receptors (regulate exit of lymphocytes from lymph nodes)

28
Q

immunodepleters

A

deplete immune cells - kill lymphocytes and B cells

ex. ALEM: monoclonal antibody kills lymphocytes (but not stem cells)
ex. OCR: B cell depleter

29
Q

safety vs efficacy

A

medications that can modulate aspects of the immune system
more effective = more severe and higher risks
safer = less effective