Multiple Sclerosis Flashcards
Who is usually affected by MS?
- It is a disease of young people
- F:M 2-3:1
What is MS?
It is a white matter disease of the centre nervous system with focal disturbance of function
What do most MS patients develop?
Progressive disability
What type of course does MS have?
Relapsing remitting course
What is demyelination?
An auto immune process where there is acute inflammation of myelin sheath which leads to loss of function
What is the cause of demyelination?
Activated T cells cross blood brain barrier causing demyelination
What signs of demyelination may be seen on MRI?
Lesions or plaques
What may post inflammatory gliosis produce?
May have functional deficits
What process may be important in disease progression?
Axonal loss may be important in disease progression and development of persistent disability
What suggest cerebral atrophy on MRI?
Black holes on MRI
What is the prevalence of MS?
Prevalence ~190 per 100 000 in Scotland
What is MS associated with?
It has complex genetic inheritance and is associated with autoimmune disease
Where is MS commoner?
Temperate climate
What do 80% of MS cases present with?
A relapse
What is the usual timeline of initial presentation of MS?
- Gradual onset over days
- Stabilises days to weeks
- Gradual resolution to complete or partial recovery-
How may MS relapse present?
- Optic neuritis -Sensory symptoms
- Limb weakness
- Brainstem Diplopia/Vertigo/Ataxia
- Spinal cord-bilateral symptoms and signs +/- bladder
Describe optic/retrobulbar neuritis which can occur in MS.
- Subacute visual loss
- Pain on moving eye
- Colour vision disturbed
- Usually resolves over weeks
- Initial swelling optic disc
- Optic atrophy seen later
- Relative afferent pupillary defect
What is the differential diagnosis for optic neuritis?
- Neuromyelitis optica
- Sarcoidosis
- (Ischaemic optic neuropathy)
- Toxic/ drugs/ B12 deficiency
- Wegeners granulomatosis
- (Local compression)
- Lebers hereditary optic neuropathy
- Infection-borrelia
What signs/symptoms can occur with a brainstem relapse?
- Cranial nerve involvement
- Pons- internuclear ophthalmoplegia
- Cerebellum -vertigo, nystagmus, ataxia
- Upper motor neurone changes limbs
- Sensory involvement
How does myelitis present?
- Partial or Transverse (complete)
- Sensory level often with band of hyperaesthesia
- Weakness/ upper motor neurone changes below level
- Bladder and bowel involvement
- May be painful
What is the differential for myelitis?
- Inflammation: Devics, SLE, sarcoidosis
- Infection/Post infection: HIV, HTLV, HSV, TB, Borrelia, Mycoplasma
- Tumour
- Paraneoplastic process
- Stroke
What must occur for a diagnosis of MS?
Separate episodes of demyelination disseminated in space and time
When may further relapses occur?
May occur within months or years of first relapse
How can further relapses present?
Vary in site and severity
- Optic nerve
- Sensory
- Limb weakness
- Diplopia
- Vertigo
- Ataxia
- Sphincter disturbance
What can occur in the progressive phase of MS?
Accumulation of symptoms and signs
- Fatigue, temperature sensitivity
- Sensory
- Stiffness or spasms
- Balance, slurred speech
- Swallowing
- Bladder & bowel
- Diplopia/ oscillopsia/ visual loss
- Cognitive-dementia/ emotional lability
What may be found on examination of MS?
Depends on where demyelination has occurred and stage of disease:
- Afferent pupillary defect
- Nystagmus or abnormal eye movements
- Cerebellar signs
- Sensory signs
- Weakness
- Spasticity
- Hyperreflexia
- Plantars extensor
How can MS be diagnosed?
May be clinical or MRI based diagnosis
- Posers criteria (requires 2 clinical episodes)
- Macdonald Criteria (MRI)
What is a lesion/plaque?
Area of demyelination on MRI scan
How do lesions correspond to relapses?
For 10 lesions (approximately) patient experiences 1 relapse
How should MRIs be interpreted?
- White areas do not necessarily mean MS
- Active lesions will appear white whereas old lesions cannot be seen without contrast
How should MS be investigated?
Depends on clinical picture……
- Lumbar puncture-oligoclonal bands present in CSF but not serum
- Visual/ somatosensory evoked response
- Bloods-exclude other inflammatory conditions
- Chest X Ray
What does the differential diagnosis for MS depend on?
Depends on symptoms and signs and on whether a first relapse or progressive disease
What types of MS are there?
- Relapsing remitting-85% at outset (RRMS)
- Secondary progressive (SPMS)
- Primary progressive – 10-15% (PPMS)
- Sensory – 5%
- Malignant
Describe relapsing remitting MS.
- Episodes vary in severity
- Vary in duration
Describe secondary progressive MS.
- Relapses with recovery
- Followed by progressive relapse with no recovery
Describe sensory MS
-Relapsing with low severity
How can MS progress?
- 1/4 MS never affects activities of daily living (ADL)
- 15% severely disabled quickly
- 1 in 4 will require a wheel chair at some point
What are good prognostic indicators for MS?
- Female
- Present with optic neuritis
- Long interval between 1st and 2nd relapse
- Few relapses in 1st 5 years
What are bad prognostic indicators for MS?
- Male
- Older age
- Multifocal symptoms and signs
- Motor symptoms and signs
Describe primary progressive MS.
First episode does not resolve but progresses a continuous episode
When does primary progressive MS usually present?
Often presents in 5th and 6th decade
What types of symptoms are present in primary progressive MS?
- Spinal symptoms
- Bladder symptoms
Who is affected by primary progressive MS?
M:F 1:1
What is the prognosis of primary progressive MS?
Poor
What is another name for neuromyelitis optica spectrum disorder?
Devic’s disease
How does NOSD (Devic’s disease) present?
- Optic neuritis
- Myelitis
- Aquaporin-4 antibodies
- Antibody negative in some cases
How is MS treated?
- General health and diet
- Treatment of relapse
- Symptomatic treatment
- Multi-disciplinary approach
- Disease modifying treatment
What should you look for with an acute relapse?
- Look for underlying infection
- Exclude worsening of usual symptoms with intercurrent illness
How should acute relapses be treated?
- Oral prednisolone (Intravenous)
- Rehabilitation
- Symptomatic treatment
What accounts for 25-30% of further relapses?
Underling viral infection therefore vaccination is usually advised
When may a women have fewer relapses?
Pregnancy
When may a women have an increased risk of relapse?
First 3 months post partum
What disease modifying treatments are 1st line?
s/c or i/m injections
- Beta-interferons
- Glatiramer acetate
Oral treatments
- Teriflunomide
- Dimethyl Fumarate
What are the side effects of 1st line disease modifying treatments?
Flu-like symptoms
Injection site reaction
Abnormalities of blood count and liver function
How effective are 1st line disease modifying treatments?
- Reduce relapse rate ~1/3
- No effect on progression of disability
- Not a cure
What are the 2nd line agents?
- Natalizumab monthly infusion
- Fingolimod tablets
- Alemtuzumub annual infusion
How effective is natalizumab?
Reduce relapse rate ~2/3
What is there a risk of with fingolimod?
Risk of developing Cardiac: bradyarrythmias
What is there risk of with alemtuzumub?
Risk of developing Autoimmune thyroid disease/ Goodpastures/ immune thrombocytopenic purpura
What causes multifocal leukencephalopathy?
JC virus
How is PML screened for?
- MRI annual
- Check for JC antibody blood and urine 6 monthly
Who is usually affected by PML?
Immunosuppression (AIDS)
- Natalizumab
- Dimethyl fumarate
- Fingolimod
What symptomatic treatment is there?
- Spasiticity-muscle relaxants/ antispasmodics/ physiotherapy
- Dysaesthesia-amitriptyline, gabapentin etc.
- Urinary-anticholinergic Rx, bladder stimulator/ catheterisation
- Constipation-laxatives
- Sexual dysfunction-sildenafil
- Fatigue-graded exercise, medication
- Depression-CBT, medication
- Cognitive-memory aids etc
- Tremor-aids/ pharmaceutical
- Vision/ oscillopsia-carbamazepine
- Speech/ swallowing-SALT
- Motor/ sensory impairment- multi-disciplinary team
Who is involved in the MDT?
- MS nurse
- Physiotherapy
- Occupational therapy
- Speech and language therapy
- Dietician
- Rehabilitation specialists
- Continence advisor
- Psychology/psychiatry
What can the differential diagnosis of MS include?
- Acute Disseminated -Encephalomyelitis (ADEM)
- Other Auto-immune conditions eg SLE
- Sarcoidosis
- Vasculitis
- Infection eg Lyme disease, HTLV-1
- Adrenoleucodystrophy etc etc
