Multiple Sclerosis Flashcards
What is Multiple Sclerosis?
A degenerative condition characterised by multiple episodes of CNS lesions, disseminated in time and space, not explained by anything else
What are the risk factors for developing MS?
- Lack of Vitamin D3
- Living in the northern hemisphere
- Genetic link
- Viral link (EBV)
- Smoking
How does the epidemiology of MS vary between males and females?
Females have a higher incidence (2:1) but males have more destructive lesions
What are the common patterns of disease?
- Relapsing-remitting (85%) leading to secondary progressive
- Primary progressive (15%)
Name some differential diagnoses of monophasic MS
Isolated optic neuritis, transverse myelitis or ADEM (acute disseminated encephalomyelitis)
Name some differential diagnoses of relapsing remitting MS
SLE, sarcoid, multiple strokes, Hughe’s syndrome
Name some differential diagnoses of chronic progressive MS
Metabolic (B12, thyroid, mitochondrial disease)
Structural (cervical spondylosis)
Infections (HIV, Lyme, syphilis)
What is the pathophysiology of MS?
An initial trigger starts an autoimmune reaction –> inflammation leads to defective BBB –> activated T cells enter CNS –> clones and proliferates, releasing gamma and toxic cytokines –> destruction of myelin sheath
In RR MS remyelination can occur
What is the difference in the early presentation of RR and PP MS?
PP - more lesions on spinal cord, preserved cognition
RR - more lesions on brain, cognition deteriorates
How is suspected MS investigated?
Bedside: examination
Bloods
Imaging: MRI
Special Tests: LP
What can be seen on MRI?
Periventricular and juxtacortical lesions
Persistent black holes = irreperable axonal loss
Brain atrophy
What can be seen on LP?
Oligoclonal bands - these represent the clumping of antibodies together (during electrophoresis) Abnormal protein (left over from inflammation)
What constitutes an MS attack?
Previous diagnosis of MS, could present with any symptoms as long as they last over 24 hours in the absence of a fever or other explanation
What is optic neuritis?
Unilateral visual loss, desaturation and pain on movement, due to swelling
Onset: hours-days
Recovery: days-weeks
What is transverse myelitis?
Inflammation of the spinal cord causing upper motor neurone weakness (below level of attack, with numbness and bowel and bladder disturbance
Onset: days
Recovery: weeks-months (if not recovered over 6 months, likely to be permanent)
What brainstem attacks can occur in an MS flare up?
Double vision, facial palsy, facial numbness, vertigo, dysarthria, ataxia, tremor
How should MS relapses be treated?
Anti-emetics and steroids
NB - steroids are only good for fresh inflammatory activity; they dont affect disease progression or outcome
What paroxysmal symptoms can occur in an MS flare up?
Lhermittes phenomenon Trigeminal neuralgia Tonic spasms Epilepsy Uthoffs phenomenon
What us Lhermittes phenomenon?
When putting your chin to your chest evokes an electrical shock
- seen in MS attack
What is Uthoffes phenomenon?
Inability to function in heat due to axon exhaustion (e.g. can’t get out of a hot bath)
- seen in MS attack
What members of the MDT are involved in the care of an MS patient?
Neurologist, specialist nurse, GP, voluntary, therapists, rehab/disability services, OT, PT, social services
What is the lifetime prevalence of depression with MS?
50%
What are the main symptoms of chronic MS?
Fatigue, mood changes, memory changes, visual changes, swallowing/speech, arms, arm and leg weakness, bowel and bladder disturbance, erectile dysfunction, numbness/tingling/pain, spasticity, ambulation limitations
What conditions can lead to death in MS patients?
- Aspiration pneumonia from swallowing difficulties
- UTIs from bladder problems
- LRTI/URTI from weak rest muscles
- Falls from instability
How can stem cells be used in the treatment of MS?
Umbilical cord progenitors stimulate the presence of Tregs and thus regulate T-cell activity
Name some disease modifying therapies
Current: - Teriflunomide - Dimethyl fumarate - Natalizumab - Alemtuzumab Going out of use: - Beta-interferons - Glatiramer Acetate
What are the guidelines for starting DMT?
Active RR MS (2 or more relapses in previos 2 years) or new lesions on scan
What are the pros and cons of Alemtuzamab (monoclonal antibody)?
Pros: stays in system for 5 years, unrivalled efficacy
Cons: expensive, high infection risk, thrombocytopenic purpura, thyroid problems, requires monthly monitoring of bloods
What are the pros and cons of Natalizumab (Tysabri)?
Pros: safe in pregnancy
Cons: lifelong monitoring, progressive multifocal leukoencephalopathy (fatal)
What is progressive multifocal leukoencephalopathy?
A rare viral brain infection causing inflammation of the white matter (secondary to severe immunosuppresion) .
It is caused by the JC virus, which is harmless except in the case of weakened immune systems
What are the symptoms of PML?
Clumsiness, progressive weakness, personality changes and ‘alien hand syndrome’
