Multiple sclerosis Flashcards
What is MS?
- M:F
- initial presentation?
an inflammatory demyelinating disorder the central nervous system
Plaques disseminated in time and place
Female:Male = 3:1
Initial presentation in 30s & 40s
What is the pathophysiology of MS?
Lymphocytes cross the BBB and get into brain
Attack myelin cells Inflammation and plaques MS
What is the aetiology of MS?
- genetic disposition
- environmental factors
- immune mediated
What are the 4 different courses of MS?
Relapsing remitting 90% :
-relapses over weeks and weeks, progressively gets worse then better
Secondary progressive 60%:
-gradually worsens
Relapsing progressive
Primary progressive 10-15%
-older males, never relapse
60% of relapsing remitting patients develop secondary progressive disease after 10 years
Describe the: -visual -sensory -motor -cerebellar -other features of MS
Visual
optic neuritis: common presenting feature
optic atrophy
Uhthoff’s phenomenon: worsening of vision following rise in body temperature
internuclear ophthalmoplegia
Sensory
- pins/needles
- pain
- Paraesthesia
- Dorsal column loss
- Proprioception & vibration: Rhombergs test positive (proprioception)
- Numbness
- trigeminal neuralgia
- Lhermitte’s syndrome: paraesthesiae in limbs on neck flexion
Motor (due to pyramidal dysfunction)
spastic weakness: most commonly seen in the legs
-weak extensors and strong flexors in the upper limbs and opposite in the lower limbs
Cerebellar
- ataxia: more often seen during an acute relapse than as a presenting symptom
- Intention Tremor
- Nystagmus
- Past pointing
- Pendular reflexes – when -patellar tapped the leg swings
- Dysdiadokinesis
- Dysarthria
Others
urinary incontinence sexual dysfunction intellectual deterioration
Describe what optic neuritis is?
painful visual loss
1 to 2 weeks most improve RAPD -relative afferent pupilllary defect common presenting feature in 1 eye rather than 2 colour vision goes first
What is internuclear ophthalmoplegia?
Caused by Medial longitudinal fasciculus dysfunction
Distortion of binocular vision Failure of adduction- diplopia Nystagmus in abducting eye Lag
In MS one eye may quickly look at something and then the other may have nystagmus.
If have problem in LHS, left medial LF problem so when looking right, left eye fails to adduct and right eye has nystagmus.
Describe the lower urinary tract dysfunction seen in MS?
-frequency
-nocturia
-urgency
-urge incontinence
-retention
(similar to BPH)
What is the diagnosis of MS?
(mcdonald criteria)
At least 2 episodes suggestive of demyelination
Dissemination in time and place
Clinical
MRI - diagnosis shows plaques CSF: oligoclonal bands Neurophysiology Blood tests – these should all be negative
What blood tests are carried out in the investigations of MS?
Plasma viscosity, FBC, CRP
Renal liver bone profile Auto anti body screen Borellia, HIV, syphilis serology B12 and folate
What is a clinically isolated syndrome in MS?
- First presentation suggestive of MS
- can’t tell until second event whether they definitely have MS
How to treat a: -mild -moderate -severe exacerbration of MS?
Mild-symptomatic treatment:
-Usually will get better
Moderate-Oral steroids:
-Oral methylprednisolone 500mg per day for 5 days and lansoprazole to protect stomach
Severe-Admit / IV steroids
-Come into hospital and IV methylprednisolone 1’000 mg 3 days
But steroids = side effects so ideally only do this once a year, no more than once every 3 months
-only reduces period of exacerbation
How can spasticity be managed?
Education
Physiotherapy Oral medication - baclofen,tizanidine(anti-spasmodics): start low go slow Side effects: tired/drousy/hypotension so sometimes do nothing due to s/e of treatment I.M. Botulinum toxin – this is uncommonly used in MS as not a long term solution Nerve blocks – not long term solution Intrathecal baclofen / phenol - end stage treatment Surgery
Spasticity may be helpful for pt e.g. so weak that can’t stand without spasticity so don’t want to take it all away.
How is MS pain treated?
anti convulsant eg. gabapentin
anti depressant eg. amitriptyline tens machine Acupuncture Lignocaine infusion
How is lower urinary tract dysfunction treated in MS?
bladder drill (training)
anti cholinergics eg., oxybutynin (if old tolteridine as oxybutynin can cause dementia) Desmopressin catheter - clean self intermittent or permanent
there are bladder clinics for MS patients, they do a post micturition ultrasound and see if it’s over 100 – if it is and given anticholinergics (oxybutynin) this can give urinary retention.
If someone has retention >100mls – catheter
can do this themselves 2-3 times a day
can put a permanent catheter for end stage management