Multiple Sclerosis

Question 1

What is the pathology behind multiple sclerosis?

Answer 1

discrete plaques of demyelination occurs at multiple CNS sites from T-cell mediated immune response. Demyelination heals poorly causing the relapsing and remitting symptoms

prolonged demyelination causes axonal loss and clinically progressive symptoms

Question 2

What is the mean age of onset for MS?

Answer 2

30 years old with M:F of < 1:3

Question 3

How does MS often present?

Answer 3

usually monosymptomatic - unilateral optic neuritis; numbness or tingling in the limbs; leg weakness; brainstem or cerebellar symptoms (diplopia or ataxia etc)

Question 4

What are some of the symptoms that MS can less commonly present with?

Answer 4

dysaesthesia, pins/needles, decreased vibration sense, trigeminal neuralgia
spastic weakness, myelitis
erectile dysfunction, anorgasmia, urinary retention, incontinence
swallowing disorders, constipation
diplopia, hemianopia, optic neuritis, visual phenomena, bilateral internuclear ophthalmoplegia, pupil defects
trunk and limb ataxia, intention tremor, scanning speech, falls

Question 5

What signs are suggestive of a non-MS recurrent demyelinating disease? What are examples of these diseases?

Answer 5

raised temperature, malaise, nausea, vomiting, positional vertigo, seizures, aphasia, meningism, bilateral optic neuritis, CSF leucocytosis, raised CSF protein

vasculitis or sarcoidosis

Question 6

How is MS diagnosed?

Answer 6

mainly a clinical diagnosis as no test is pathognomic

requires lesions disseminated in time and space, not attributable to other causes

Question 7

What is the appearance of the CSF in MS?

Answer 7

Oligoclonal bands of IgG on electrophoresis that are not present in serum -> suggests CNS inflammation

Question 8

What is the non-palliative pharmacological treatment options for MS?

Answer 8

steroids - methylprednisolone to shorten acute relapses
interferons (IFN-1beta and IFN-1alpha) - decrease relapses by 30% and decrease lesion accumulation
Monoclonal antibodies - alemtuzumab (acts against T cells in relapsing-remitting) Natalizumab (acts on VLA-4 receptors to stop immune cells crossing BB barrier)
Non-immunosuppressives - Glatiramer, mitoxantrone
Azathioprine

Question 9

What is the palliative management options for MS?

Answer 9

Spasticity - baclofen, diazepam, dantrolene, tizanidine
Tremor - botulinum toxin type A injections
Urgency/frequency - if post-void volume >100ml then intermittent self catheterisation, if <100 try tolterodine