Multiple Sclerosis Flashcards
What is MS?
Idiopathic inflammatory demyelinating disease of the CNS
Acute episodes of inflammation are associated with focal neurological deficits
If left untreated, patients become progressively more disabled
Name the five subtypes of MS.
Relapsing remitting MS Primary progressive MS Secondary progressive MS Progressive-relapsing MS Benign MS
What is meant by relapsing remitting MS?
Unpredictable attacks which may or may not leave permanent deficits, followed by periods of remission
What is meant by progressive relapsing MS?
Steady decline since the onset, with super-imposed attacks
What is meant by primary progressive MS?
Steady increase in disability from onset, without any attacks
What is meant by secondary progressive MS?
Initial relapsing remitting MS that suddenly begins to decline without periods of remission
Which symptoms commonly develop into MS?
Optic neuritis
Clinically isolated syndromes
Transverse myelitis
Radiologically isolated syndromes
What is optic neuritis and what is the risk of developing MS after an attack?
Painful vision loss that comes on over a few days
- demyelination of the optic nerve
- may resolve after a few weeks
30% develop MS after 5 years
50% develop MS after 15 years
Risk depends on MRI scan and oligoclonal bands in the CSF
What are the symptoms of optic neuritis?
Blurry vision
Loss of colour vision
Pain
Vision loss
What is transverse myelitis?
Inflammation of the spinal cord
Causes weakness, sensory loss and incontinence
What is a clinically isolated syndrome?
Single episode of neurological disability due to focal CNS inflammation
- e.g. optic neuritis or transverse myelitis
When is MS diagnosed?
When on MRI, there is evidence of 2 OR MORE EPISODES of DEMYELINATION, DISSEMINATION in SPACE AND TIME.
- inflammation of two different parts of the CNS - disseminated in space
- evidence of active and past inflammation - disseminated in time
What causes MS?
Genetic factors - low in China
Sunlight/Vit D
Viral triger (EBV)
Smoking (increases rate of disability progression)
When should you suspect MS in a patient?
Neurological symptoms that develop over a few days
A history of transient neurological symptoms that lasted 24 hours and spontaneously resolved
Hidden relapses
- optic neuritis
- Bell’s palsy
- labyrinthitis
- sensory symptoms
- bladder symptoms in young men and women without children
List some of the main symptoms of MS.
Depends on the area of demyelination
- fatigue
- depression
- optic neuritis
- dysarthria
- dysphagia
- weakness of limbs
- pain
- incontinence
- diarrhoea
What signs and symptoms indicate MS might not be the cause?
Sudden onset Peripheral signs - areflexia, glove and stocking distribution, muscle wasting and fascicualtions Major cognitive involvement Prominent seizures Pyrexia Normal MRI
What is radiologically isolated syndrome?
MRI scan performed on patient who doesnt have signs or symptoms of MS
- incidental finding that looks like MS
May develop into MS, but might not
Unnecessary distress for patient (VOMIT)
How do you investigate suspected MS with an MRI?
MRI of the brain and cervical spine with gadolinium contrast
- evidence of demyelination in 2 regions to indicate dissemination in space
- enhancing and non-enhancing areas of demyelination indicate dissemination in time
Name a T2 hyperintensity.
Dawson’s fingers
- demyelinating plaques through the corpus collosum
- specific for MS
What investigations can you do to test someone for MS?
Lumbar puncture MRI Blood - exclude other conditions Visual evoked potentials Chest X-Ray - exclude sarcoidosis
What are you looking for in the CSF after a lumbar puncture?
Oligoclonal bands - bands of immunoglobulin
Cell count - to exclude mimics
Glucose - matches blood sample
Protein
What are oligoclonal bands?
Immunoglobulin bands seen in blood and spinal fluid after protein electrophoresis
(suggests inflammation)
- suggestive of MS when bands aren’t also present in the blood (means inflammation is in the CNS)
- can be seen in other conditions or after brain surgery
What blood tests do you do if you suspect MS?
Mainly to exclude other possible causes
- B12/folate
- serum ACE
- lyme serology
- ESR/CRP (should be normal)
- ANA/ANCA/RA
- aquaporin-4 antibodies (show up in transverse myelitis and optic neuritis)
What are visual evoked potentials?
Measure of conduction of nerve signals in optic nerves to look for subclinical neuritis
- conduction is slower if patient has had optic neuritis in the past
- conduction should be the same on both sides
What is the difference between a relapse or a pseudo-relapse in MS?
Relapse
- new neurological symptoms they have never had before
- lasts more than 24 hours in the absence of temperature or infection
Pseudo-relapse
- flaring of an old area of demyelination causing re-emergance of pervious neurological symptoms (usually caused by heat or infection)
How are MS relapses managed?
Treatment isn’t always needed
High dose steroids can be used to suppress the inflammation
- not given if any evidence of inflammation
Physiotherapy
Occupational therapy
RRMS
- MRI to check for active disease and see if they need new treatment
Describe the steroid regime for relapse?
1g of IV methylprednisolone for 3 days OR 500mg oral methylprednisolone for 5 days AND PPI for gastroprotection
What are the two different methods of giving disease modifying therapies in RRMS.
Induction therapy
- therapy started with more effective drugs, but they are hard on the body
Escalation therapy
- start with less effective, but more safe drugs
Name some disease modifying drugs for RRMS.
Powerful drugs - Alemtuzumab - Natalizumab Oral treatments - Fingolimod - Dimethyl Fumerate
What are the pros and cons of Alemtuzumab?
Pros - two short courses over a year - stops relapse in 40% of patients - may improve disability Cons - high risk of secondary autoimmune problems (thyroid, ITP)
What are the pros and cons of Natalizumab?
Pros - monthly infusions - very effective Cons - serious risk of fatal PML is infected with JC virus
What are the pros and cons of Fingolimod?
Pros
- less side effects compared to the more powerful drugs
Cons
- daily tablet
- less effective than natalizumab or alemtuzumab
- risk of infection
- slows heart rate
What are the pros and cons of dimethyl fumerate?
Pros - less side effects compared to the more powerful drugs Cons - twice daily tablet - less effective than Fingolimod - low WCCs - risk of infections
Name some of the older treatments for MS.
Beta interferon and Copaxone
- less effective than Fingolimod or monoclonal antibodies
What is the cause of primary progressive MS?
JC virus
- can lead to PML in the immunocompromised
- progressive destruction of white matter in the brain
How is primary progressive MS diagnosed?
At least one year of disease progression
MRI scan supports diagnosis of MS
Oligoclonal bands support diagnosis of MS
How is secondary progressive MS diagnosed?
When they have had RRMS in the past, but have no started exhibiting signs of progressive disease without relapses on scan
What is the treatment for progressive MS?
Treating symptoms
Effective treatment for RRMS reduces progression to secondary progressive MS.
Potential treatment for PPMS - ocrelizumab
Potential treatment for SPMS - siponimod
Describe the symptom management for secondary progressive MS
Rehabilitation
Control symptoms of the bladder, fatigue, mood, spacicity and mobility
