Multiple sclerosis

Question 1

What are the different presentations of multiple sclerosis?

Answer 1

• Depending on where the demyelination is can mean that there are different presentations of MS
• There is a gradual onset over days
• Stabilises in days or weeks
• There is a gradual resolution to complete or partial recovery
• Symptoms include:
- Sensory symptoms
- Limb weakness
- Brainstem diplopia (double vision), vertigo or ataxia (lack of voluntary muscle movements)
- Spinal cord bilateral symptoms and signs +/- bladder
- Optic neuritis
- Myelitis
• Needs two isolated episodes in a different place each to diagnose as MS
• In the progressive stage there is an accumulation of signs and symptoms

Question 2

Explain optic neuritis in MS

Answer 2

• Subacute visual loss
• Pain on moving the eye
• Colour vision disturbed
• Resolves over weeks (usually)
• Initial swelling on optic disk
• Optic atrophy seen later
• Relative afferent pupillary defect

Question 3

Explain myelitis in MS

Answer 3

• Partial or transverse (complete)
• Starts with pins and needles in the feet which ascend to sensory level
• Sensory level often has hyperesthesia
• Weakness/ upper motor neuron changes below level
• Bladder and bowel involvement
• May be painful

Question 4

What are the signs and symptoms that accumulate in the progressive stage?

Answer 4

• Fatigue
• temperature sensitivity
• Sensory
• Stiffness or spasm
• Balance
• Slurred speech
• Swallowing
• Bladder and bowel
• Diplopia/ oscillopsia (visual field appears to oscillate)/ visual loss
• Cognitive dementia/ emotional lability

Question 5

What are the different courses of MS?

Answer 5

• Relapsing-remitting (85%): have an episode and then either fully recover or partially recover and there is no change until the next episode
• Secondary progressive: People with relapsing remitting go on to develop progressive where the disabilities get worse over time (even if there are no episodes)
• Primary progressive (10-15%): There is no relapsing-remitting stage, it just goes straight to the progressive stage
• Sensory (5%)
• Malignant

Question 6

How do you diagnose MS?

Answer 6

• Posers criteria: 2 clinical episodes
• Macdonald’s criteria: past episodes can be diagnosed via MRI
• Other investigations
- Lumbar puncture: oligoclonal bands present in CSF but not serum
- Visual/somatosensory evoked response
- Bloods: exclude other inflammatory conditions (glucose and protein should be normal in MS)
- Chest x-ray
• Differential diagnosis
- Acute disseminated encephalomyelitis (ADEM)
- Other autoimmune diseases
- Sarcoidosis
- Vasculitis
- Infection e.g. Lyme disease, HTLV-1
- Adrenoleukodystrophy etc etc

Question 7

What is the treatment for MS?

Answer 7

There is no cure

Question 8

How is an acute relapse managed in MS?

Answer 8

• Look for underlying infection, treatment of the infection can also help the relapse (also giving steroids would make it worse)
• Oral prednisone (intravenous): 1g
• Rehabilitation
• Symptomatic treatment

Question 9

What are the 1st line disease modifying agents of MS?

Answer 9

• Slightly reduces the number of relapses (~1/3)
• No effect on progression of disability
• Subcutaneous or intramuscular injections (self-administered): Beta-interferons or glatiramer acetate
• Oral treatments: Teriflunomide or Dimethyl fumarate
• Side effects: Flu-like symptoms, injection site reaction, abnormalities in blood count or liver function

Question 10

What are the third line disease modifying agents of MS?

Answer 10

• Natalizumab: monthly infusion (reduced relapse rate ~2/3)
• Fingolimod (tablets): Less effective than natalizumab and can cause arrhythmia and so the first time you take them you need to be monitored
• Alemtuzumab: this is very effective but isn’t very pleasant and increases the risk of quite a few things (autoimmune thyroid disease, Goodpasture, immune thrombocytopenic purpura)

Question 11

What is the symptomatic management of MS?

Answer 11

• Spasticity: muscle relaxants/ antispasmodics/ physiotherapy
• Dysesthesia: amitriptyline, gabapentin etc.
• Urinary: anticholinergic Rx, bladder stimulator/ catheterisation
• Constipation: laxatives
• Sexual dysfunction: Sildenafil
• Fatigue: graded exercise, medication
• Depression: CBT, medication
• Cognitive: memory aids
• Tremor: aids/ pharmaceutical
• Vision/ oscillopsia: carbamazepine
• Speech/ swallowing: SALT
• Motor/ sensory impairment: multi-disciplinary team