Multiple Sclerosis Flashcards
what does relapsing remitting mean?
there are episodes of symptoms
why does demyelination occur in MS?
> autoimmune process
activated T cells cross blood brain barrier causing acute inflammation of the myelin sheath
leads to demyelination
what is post inflammatory gliosis?
functional deficit after attack
what appears on an mri in MS?
> pale patches or lesions
> black holes later on
what are the black holes seen on MRI?
cerebral atrophy
what is the prevalence of MS in Scotland?
190 per 100000
how are affected more males or females?
females
what climate is MS commoner in?
temperate climate
what sort of condition is MS associated with?
autoimmune disease
what do most MS cases present with?
> relapse (an attack of inflammation)
gradual onset
stabilises in days to weeks with gradual resolution
describe relapse symptoms
> optic neuritis > sensory symptoms > limb weakness > vertigo > ataxia > diplopia > bladder problems
describe optic neuritis
> sub-acute visual loss (and colour vision) > pain on eye movement > initial swelling of optic disc > optic atrophy seen later > afferent pupillary defect > resolves over a couple of weeks
what is the differential for optic neuritis?
> MS > neuromyelitis optica > sarcoidosis > ischaemic optic neuropathy > B12 deficiency > wegeners granulomatosis > local compression > lebers hereditary > infection
what can occur in a relapse involving the pons?
internuclear opthalmoplegia
what can occur in relapse involving the cerebellum?
> vertigo
nystagmus
ataxia
describe myelitis
> can be partial or transverse >sensory level often with band of hyperaesthesia (excessive skin sensitivity) > weakness (upper motor neuron changes) > bladder and bowel involvement > painful (sometimes)
what is the differential diagnosis for myelitis?
> inflammation (Devics, SLE, sarcoidosis) > infection (post) > tumour > paraneoplastic process > stroke
would an isolated incident of demyelination be enough to diagnose MS?
no, episodes of demyelination disseminated in space and time
describe the progressive phase
there is an accumulation of symptoms and signs including: fatigue stiffness balance issues bladder issues vision issues cognitive issues
what will examination findings depend on?
where demyelination has occurred and the stage of the disease
what eye signs might you see on examination of someone with MS?
> afferent pupillary defect
nystagmus
abnormal eye movements
what might you see in a limb examination of someone with MS?
> weakness
spasticity
hyper-reflexia
plantar extension
how would you diagnose MS?
> evidence of demyelination separated by time and space
poser criteria (clinical)
macdonald criteria (MRI)
for 10 lesions a patient may experience how many relapses (approximately)?
one
what other examination could you carry out depending on the clinical picture?
> lumbar puncture
visual/somatosensory evoked response
bloods (excludes other inflammatory conditions)
chest x ray
what would you look at in a lumbar puncture?
if oligoclonal bands were present in the CSF but not in the serum
what does the differential diagnosis depend on?
the symptoms and signs and whether the first relapse or progressive disease
name some types of MS
> relapsing remitting > secondary progressive > primary progressive > sensory > malignant
describe secondary progressive
after a relapsing remitting form of disease there is a steady increase in impairment
what number of people with MS will require a wheelchair?
1 in 4
what are indicators of a good prognosis?
> female
present with optic neuritis
long interval between 1st and 2nd relapse
few relapses in the 1st 5 years
what are bad prognostic indicators?
> male
older
multifocal symptoms and signs
motor symptoms and signs
describe primary progressive MS
there is a steady increase in impairment over time with no relapses and a poor prognosis.
often presents in the 5th or 6th decade.
describe devics disease(neuromyelitis optica spectrum disorder)
> inflammatory disorder of the CNS
optic neuritis
myelitis
involving aquaporin-4antibodies
what is the treatment for devics disease?
> health and diet > relapse treatment > symptomatic treatment > multi-disciplinary approach > disease modifying treatment
what is the management for an acute relapse of devics disease?
> look for underlying infection
oral prednisolone
rehabilitation
symptomatic treatment
what is the effect of pregnancy on relapse in devics disease?
there are fewer relapses during pregnancy but increased risk in the first 3 months post partum
what are the first line disease modifying treatments for devics disease?
> beta interferons
glatiramer acetate
teriflunomide
dimethyl fumerate
what are the side effects of first line disease modifying treatment in devics disease?
> flu like symptoms
injection site reactions
abnormalities of blood count and liver functions
what are the effects of first line disease modifying treatments in devics disease?
> reduced relapse rate by 1/3
> no effect of disability progression
what are second line agents in devics disease?
> natalizumab (monthly infusion)
fingolimod tablets
alemtuzumub
what is progressive multifocal leukencephalopathy caused by?
jc-virus
what is the management for multifactorial leukencephalopathy?
> immunosuppression (natalizumab, dimethyl fumarate, fingolimod)
annual MRI
JC antibody and urine 6monthly
symptomatic treatment
