Multiple Sclerosis Flashcards
Outline the process and features of MS
A relatively common neurological disease affecting primarily young people. The presentation and severity is variable, prognosis is uncertain
Disease affects the white matter of the CNS, demyelinating axons causing focal disturbance of function-relapse. Most patients develop progressive disability
Describe the process of demyelination
Auto immune - activated T cells cross blood brain barrier causing demyelination, acute inflammation of the myelin sheath and loss of function
What can be seen on the brain MRIs of patients with MS?
White lesions/plaques
What features are seen on MRI in patients with advanced MS?
Black holes that are later seen as cerebral atrophy
What are the general demographics of MS?
20s-30s affected
Females more than males
Less common in Asia
Describe the initial presentation of patients with MS
80% percent present with a relapse - an attack of demyelination
Gradual onset over days that stabilises after days/weeks
What symptoms can characterise an MS relapse?
Optic neuritis Sensory symptoms Limb weakness Diplopia/Vertigo/Ataxia - Brainstem Spinal cord - bilateral symptoms and bladder signs
What is the one line definition of MS?
Episodes of demyelination disseminated in space and time
Describe optic/retrobulbar neuritis
Subactue visual loss Painful on movement Colour vision disturbed Initial swelling oft he optic disk Optic atrophy seen later Relative afferent pupillary defect
What are some differential diagnoses for optic neuritis?
Neuromyelitis optica Sarcoidosis Ischaemic B12 deficiency Wegners Herpes simplex
What happens in the progressive phase of MS?
An accumulation of symptoms and signs that include Fatigue, temp sensitivity Sensory signs Stiffness or spasms Balance, slurred speech Swallowing Bladder & bowel Visual defect Cognitive defect - dementia/emotional lability
What are some signs that can be found on examination of a patient with MS?
Afferent pupillary defect Nystagmus/abnormal movements Cerebellar signs Sensory signs Weakness Spasticity Hyperreflexia Plantars extensor
What is necessary for diagnosis of MS?
Evidence of demyelination separated in time and space
What is the name of the clinical criteria for diagnosis of MS?
Posers
What is the name of the MRI criteria for diagnosis of MS?
Macdonald
Other than MRI what investigations can be done for MS, depending on the clinical picture?
LP
Visual evoked response
Bloods
CXR
Give some differential diagnoses for MS
Acute Disseminated Encephalomyelitis Autoimmune e.g. SLE Sarcoidosis Vasculitis Infection e.g. Lyme disease
What is the main form of MS? What are the other forms?
Relapsing remitting - 85% at outset
Secondary progressive
Primary progressive
Sensory
Malignant
What is the common outcome when patients present with a relapse?
They develop secondary progressive disease
75% after 35 years
What are positive/good prognostic factors for predicting MS progression?
Female
Present with optic neuritis
Long interval between first and second relapse
Few relapses in the first 5 years
What are some negative/bad prognostic factors for predicting MS progression?
Male
Older age
Multi-focal symptoms and signs
Motor symptoms and signs
When does primary progressive MS most commonly present? What are the features?
5th and 6th decade
No relapses, progression is continuous
Often spinal problems
Prognosis is poor
Outline the pathogenesis of MS?
Complex genetic inheritance
Association with autoimmune disease
Commoner in temperate climate
What are the treatment principes in MS?
Disease modification
General health and diet
Treatment of relapse
Symptomatic treatment
Multi-disciplinary!!
What are the main disease modifying pharmacological treatments for MS? What are the features of these drugs?
Beta-interferons/glatiramer acetate/teriflunomide/dimethyl fumarate - regular sc injections
Reduce relapse rate by around a third but do not cure the disease and have no effect on the progression of disability
Give some side effects of disease modifying treatments
Flu-like symptoms
Injection site reaction
Abnormalities of blood count and liver function
What is the main second line agent used in MS treatment? What are the effects and what is a significant associated risk?
Natalizumab
Can reduce relapses up to two thirds
There is a 1:1000 ris of developing progressive multifocal leukoencephalopathy - cumulative risk?
What are the treatment priorities when a patient presents with an acute MS relapse?
Look for underlying infection !!!
Exclude worsening of usual symptoms with intercurrent illness
Give oral prednisolone (iv)
Rehabilitation
Symptomatic treatment
What is often the cause of futher MS relapses?
Viral infection - vaccinations usually advised
Give some examples of symptoms occurring in MS relapses and their treatment
Spasticity - muscle relaxants/antispasmodics/physiotherapy Urinary - anticholinergic Rx, bladder stimulator/catheterisation Constipation - laxatives Sexual dysfunction Dysaesthesia (abnormal unpleasant feeling when touched) - amitriptylline, gabapentin etx Fatigue - graded exercise, medication Depression - CBT, medication Tremor - aids/medication Vision/oscillospia - carbamazepine Speech/swallowing - SALT
GIve some examples of people who could make up the multi-disciplinary team that is integral to MS care
MS nurse Physio OT SALT Dietitian Rehab specialists Psychology
