Multiple Sclerosis Flashcards
Define MS
Inflammatory Autoimmune Demyelinating (white matter) disease of the CNS.
When does MS generally present?
In young people from their teens->30s
Primary Progressive (PPMS) tends to show up later in life (50s/60s)
Who is predisposed to MS?
People with other autoimmune conditions
Describe the prevalence of MS?
In scotland its roughly 190/100,000
2 or 3x more common in women than men
Most common in white northern countries such as the UK & Canada. (Possibly because of less sunlight, as Vit D deficiency is a risk factor for MS)
How do most MS sufferer’s initially present?
In early life during a relapse
A few days gradual onset of symptoms then it takes a few weeks to stabilize and they recover slowly in hospital.
What types of relapses are common in MS?
- Optic Neuritis
- Spinal Cord (Myelitis)
- Brain Stem & Cerebellar
- Sensory symptoms
- Limb Weakness
What symptoms are a part of optic neuritis?
- Subacute visual loss
- Pain on moving the eye
- Colour vision disturbed
- Swelling and/or atrophy of the optic disc
- Relative afferent pupillary reflex (pupils reacting differently to light)
What are the types of myelitis?
Partial (one sided) or transverse (complete)
What are the effects of myelitis?
- Weakness & UMN syndrome below the level of the myelitis
- The affected level may have hyperaesthesia (physical hypersensitivity)
- Bladder & Bowel Symptoms
How would a brainstem relapse present?
- Cranial Nerve Involvement
- Cerebellum (Vertigo, ataxia, nystagmus)
- Can affect the sensory fibres or UMNs
- Internuclear Opthalmoplegia
What is internuclear opthalmoplegia
Occurs due to MS affecting the Pons, (specifically the nerve fibres connecting the nuclei of VI & III)
Ipsilateral slow & deficient adduction + Contralateral Abducting Nystagmus
when you look contralateral to the effected eye.
What kind of sensory symptoms can occur in an MS relapse?
Numbness, tingling, lack of sensation or pain are common
What kind of motor symptoms come with an MS relapse?
- Clumsiness
- Spasticity
- Tremors
- Weakness
- Hypereflexia
etc
Dsecribe the progression of MS?
Most MS presents with a relapse:
- Then the relapse heals and the disease follows a pattern of relapse & remission, possibly with some permanent disability developing after each relapse
- Most people eventually develop Secondary Progressive MS where the disease remains active between relapses resulting in progressively worsening disability
What sort of effects can develop in progressive MS?
- Fatigue
- Unusual sensation
- Stiffness, spasms, weakness, hyperreflexia, plantar extension
- Speech & swallowing problems
- Bladder & bowel symptoms
- Visual loss/oscillopsia/diplopia
- Balance problems
- Cognitive. Mainly mild memory impairment
How do we diagnose MS?
Either clinically using Poser’s Criteria
Or by MRI using Macdonald’s Criteria
Remember MS is recurrent episodes of demyelination disseminated by time & space, just one episode isnt yet MS
How does MS appear on an MRI?
- Sites of recent inflammation show up as white lesions or plaques
- Axonal loss then appears as black holes and in severe cases as cerebral atrophy
If you are unsure its MS after an MRI, what other tests can be done?
- Bloods looking for other inflammatory conditions
- CXR for inflammatory conditions like Sarcoid
- LP, oligoclonal bands in CSF but not in the blood indicates MS
What are the types of MS?
- Relapsing Remitting (RRMS) 85% of cases at the outset
- Secondary Progressive (SPMS)
- Primary Progressive (PPMS)
- Sensory MS
- Malignant MS
Describe the pattern of Relapsing Remitting MS?
Episodes of demyelination causing varying severity of symptoms with complete recovery between relapses
(most eventually become SPMS)
Describe the pattern of Secondary Progressive MS?
Relapses with progressively worsening disability
Describe the pattern of Sensory MS?
Minor episodes of sensory symptoms with good recovery
Describe the pattern of primary progressive MS?
Progressively worsening disability right from the outset
What would indicate a worse prognosis for MS?
- Male
- Older
- Multifocal Signs/Symptoms
- Motor Symptoms
- Close 1st & 2nd relapse
- Lots of relapses in the 1st 5 yrs
Whats different about Primary Progressive MS?
It usually presents in the 50s or 60s rather than in youth
Its even between genders (MS is generally more common in women)
Poor Prognosis
What is Devic’s Disease?
Neuromyelitis Optic Spectrum Disorder
It used to be considered a varient of MS but is now considered its own clinical entity.
Its myelitis and optic neuritis mediated by aquaporin-4 antibodies and treated with immunosuppression
How do we treat an acute relapse of MS?
- Look for an underlying infection
- IV or Oral Prednisalone
- Rehabilitation
- Symptom treatment
Also vaccinate against viral infections to reduce future relapses
What are disease modifying treatments?
Treatments that reduce the relapse rate
however they dont slow progression or reduce the severity of the disease
What are the types of 1st line disease modifying treatments?
SC/IM injections (e.g. Beta-interferons)
Oral (E.g. Teriflunomide)
What are the side effects of 1st line disease modifying treatments?
- Flu-like Symptoms
- Abnormal blood count or liver function
- Injection site reaction
List some second line disease modifying treatments?
- Monthy Infusion of Natalizumab
- Yrly Infusion of Alemtuzumub
- Tablets of Fingolimod
Name one side effect of Fingolimod tablets?
Arrythmias
All these disease modifying treatments are immunosupressants. What kind of conditions does this increase your risk of?
Other infections and autoimmune conditions suhc as:
- Autoimmune Thyroid Disease
- Immune Thrombocytopenic Purpura
- Goodpasture’s Disease
- Progressive Multifocal Leukoencephalopathy (PML)
What is PML and how does it relate to MS?
Progressive Multifocal Leukoencephalopathy
A severe demyelinating disease of the brain caused by the JC virus
People on MS disease modifying treatments are predisposed to PML so get an annual MRI and JC antibody blood/urine tests every 6 months
We also give symptomatic treatment to help people manage MS, such as?
- Muscle relaxants, antispasmodics & physiotherapy for motor symptoms
- Anticholinergics for Overactive bladder
- Bladder stimulators
- Laxatives for constipation
- Graded exercise & meds for fatigue
- CBT & meds for depression
- Speech & language therapy for speech problems
- Can also help with tremors and memory impairment
Whos included in an MS MDT?
- MS nurse
- Physiotherapy
- Occupational Therapy
- Dieticians
- Speech & Language Therapists
- Psychology/Psychiatry
- Continence Advisors
- Rehab Specialists
What is L’hermittes Sign?
A sudden electric shock travelling down your neck into your spine and somtimes to your limbs when you bend you head forward.
Its due to miscommunication between nerves in the spine that are no longer seperated by myelin sheaths
