Multiple sclerosis Flashcards
What is multiple sclerosis?
An autoimmune condition characterised by episodes of inflammation of the nervous tissue in the CNS, causing demyelination
Describe the aetiology of MS
Females (3:1)
20-40 y/o
More common as you move away from the equator
What are some factors that cause MS?
At least 60 genes have been implicated (HLA, MHC, etc.)
Environmental factors (EBV, VitD deficiency)
Describe the pathophysiology of MS
T-cell mediated autoimmune response against the white matter of the brain and spinal cord
Plaques of demyelination can occur anywhere but occur most commonly in the optic nerve, brainstem and cervical spinal cord
How does lower urinary tract dysfunction occur in MS?
CNS demyelination causes increased tone at the bladder neck as well as detrusor muscle hypersensitivity and sphincteric dyssenergia
What are the 3 main patterns of MS?
Relapsing-Remitting MS
Secondary progressive MS
Primary progressive MS
Describe the pattern of relapsing-remitting MS
Symptoms occur in attacks (relapses) with a characteristic time course: onset over days and typically recovery, either partial or complete, over weeks
Describe the pattern of secondary progressive MS
This late stage of MS consists of gradually worsening disability progressing slowly over years; some 75% of patients with relapsing-remitting MS will eventually evolve into a secondary progressive phase by 35 years after onset
Describe the pattern of primary progressive MS
Characterized by gradually worsening disability without relapses or remissions
What are the types of presentations of MS
Pyramidal dynsfunction
Optic neuritis
Sensory symptoms
Lower urinary tract dysfunction
Cerebellar dysfunction
Brainstem dysfunction
Internuclear ophthalmoplegia
Fatigue
What are some symptoms of pyramidal dysfunction?
- Increased tone
- Spasticity
- Weakness
- Affects extensors of upper limbs and flexors of lower limbs
What are some symptoms of optic neuritis?
Painful visual loss over 1-2 weeks
Blurred vision (Unilateral)
Reduced or lost colour vision
RAPD
What are some sensory symptoms of MS
- Pain
- Paraesthesia
- Dorsal column loss - proprioception and vibration
- Numbness
- Trigeminal neuralgia
- Odd sensation on neck flexion (Lhermitte’s sign)
What are some symptoms of lower urinary tract dysfunction?
- Increased frequency and urgency
- Nocturia
- Urge incontinence
- Retention
What are some symptoms of cerebellar dysfunction in MS?
- D - Dysdiadochokinesia
- A - Ataxia
- N - Nystagmus
- I - Intention tremour
- S - Slurred speech
- H - Hypotonia
What are some symptoms of brainstem dysfunction in MS?
- Diplopia - CN VI palsy
- Facial weakness - CN VII palsy
What is internuclear ophthalmoplegia?
A condition in which there is formation of a demyelinated plaque in the medial longitudinal fasciculus
What are some symptoms of internuclear ophthalmoplegia?
- Distortion of binocular vision
- Failure of adduction - diplopia
- Nystagmus in abducting eye
- Lag
What are some investigations required in MS?
Bloods
Neurophysiology
MRI
Lumbar puncture
What bloods are required in MS?
Bloods to rule out other causes:
- FBC
- Inflammatory markers
- U&Es
- LFT, TFT
- Glucose
- HIV serology
- Calcium
- B12 levels
What will be seen on MRI in MS?
- Periventricular lesions
- Discrete white matter abnormalities
- Areas of focal demyelination
- Active inflammatory plaques can be distinguished from inactive ones by using a contrast agent
What will be seen in the CSF on lumbar puncture?
Oligoclonal bands
How is acute relapse of MS managed in MS
Mild - Symptomatic treatment
Moderate - Oral steroids
Severe - Admit/IV steroids
How is pyramidal dysfunction managed in MS?
- Physiotherapy
- Occupational therapy
- Anti-spasmodic agent e.g. oral baclofen, oral tizanidine, botulinum toxin, intrathecal baclofen
How are sensory symptoms managed in MS?
- Anticonvulsant e.g. gabapentin
- Antidepressant e.g. amitriptyline
- TENS machine
- Acupuncture
- Lignocaine infusion
How is lower urinary tract dysfunction managed in MS?
- Bladder drill
- Anti-cholinergics e.g. oxybutynin
- Desmopressin
- Catheterisation
How is fatigue managed in MS?
- Amantadine
- Modafinil if sleepy
- Hyperbaric oxygen
What is first line disease modifying therapy in MS?
- Tecfedira, aubagio
- Interferon beta
- Glitiramer acetate
What is second line disease modifying therapy in MS?
- Monoclonal antibody - tysabri, ocrevus, lemtrada
- Anti-CD20, anti-CD 50, Anti-integrin
- Fingolimod, cladrabine
What is third line disease modifying therapy in MS?
- Mitoxantrone
- HSCT (stem cell transplantation)
