Multiple Sclerosis Flashcards
What is multiple sclerosis
Inflammatory demyelinating disorder the central nervous system
Autoimmune reaction against myelin
Characterised by distinct episodes of neurological deficits, separated in time
Is MS more common in men or women
Women
3:1 ratio
At what age does MS usually present
20s - 40s
What are the risk factors for MS
Link with the EBV
Vit D deficiency may be associated
Gets more common the further from the equator you go - for both northern and southern hemispheres
Genetic predisposition and environmental trigger
What is the most common clinical course for MS
Relapsing and remitting - periods of illness followed by a good period
Some go onto be secondary progressive – relapse pattern which then starts getting slowly worse
What is a progressive relapsing (secondary progressive) illness pattern
Periods of illness/symptoms that do get better but you never get back to baseline
Get progressively worse each time
What is a primary progressive disease pattern
Just gets gradually worse over time
What are the common clinical features of MS
Pyramidal dysfunction Optic neuritis Sensory symptoms Lower urinary tract dysfunction Cerebellar & brain stem features Cognitive impairment
However, almost anything can happen as nerves become affected
Describe pyramidal dysfunction
Increased tone - velocity dependant
Spasticity
Weakness:
Extensors of upper limbs
Flexors of lower limbs
What is optic neuritis
Painful visual loss - usually unitlateral
Caused by inflammation in the nerves that move the eyes
Worse on movement of the eye
Will get a RAPD
What are the sensory symptoms of MS
Pain
Paraesthesia
Dorsal column loss - proprioception and vibration
May get burning sensation or the feeling of water running down legs
Trigeminal neuralgia
Numbness
You should scan everyone with trigeminal neuralgia - true or false
True
Need to rule out MS as the cause
How does cerebellar dysfunction present
Dysdiadokinesis Ataxia Nystagmus Intention tremor Speech issue - dysarthria Pendular reflexes
What causes diplopia in MS
CN VI palsy
What can lead to facial weakness in MS
CNVII palsy
How does internuclear ophthalmoplegia present
Distortion of binocular vision
Failure of adduction leading to diplopia
Nystagmus
Lag -one eye will move quickly and the other will drag behind it
What symptoms of lower urinary tract dysfunction are common in MS
Increased frequency Nocturia Urgency Urge incontinence Retention
How can you treat fatigue
Amantadine
Modafinil if sleepy
Hyperbaric oxygen
What investigations would you do for MS
MRI of brain and spinal cord - will show lesions (usually in white matter)
CSF - look for IgG oligoclonal bands
Blood tests - inc. B12/folate, connective tissue screen
What other diagnosis can present similarly to MS
Vasculitis Granulomatous disorder Vascular disease Structural lesion Infection - HIV, syphilis and Lyme disease Metabolic disorder
What would you expect to to see in the CSF of someone with MS
Unmatched oligoclonal bands
seen in 90% of cases
How do you manage an acute exacerbation of MS
Mild - just symptomatic
Moderate - oral steroids
Severe - admit and give IV steroids
Balance risk of steroids with benefits of treatment
What are the risks of steroid treatment
Hypertension
AVN
How can you treat pyramidal dysfunction
Physiotherapy
Occupational therapy
Anti-spasmodic agent - baclofen, tizanidine, botox
How can you treat the sensory symptoms of MS
Gabapentin or amitriptyline for pain
Tens machine
Acupuncture - specialist nurse service
Lignocaine infusion
What is dyssynergia of the bladder
Where the bladder neck and detrusor contract at the same time
Uncoordinated so doesn’t work properly
How can you treat lower urinary tract dysfunction in MS
Bladder drill
Anti cholinergic eg., oxybutynin
Desmopressin
Catheterisation
What are the first line DMARDs in MS
Used for those with relapses Interferon beta Glitiramer acetate These are injectable Tecfedira - oral
What are the second line DMARDs in MS
Used for continued relapse after 1st line or in those with severe presentations
Monoclonal antibodies - tysabri
Cladrabine/fingolimod - oral
What are the 3rd line DMARDs in MS
This is end stage treatment
Mitoxantrone
Stem cell transplant
What is the role of MRI in prescribing DMARDs
Repeat scans to monitor disease progression
Determines whether treatment with DMARDs needs escalated
What is the risk of giving monoclonal antibodies such as tysabri in MS treatment
Can cause Progressive multifocal leukoencephalopathy (PNL) if the patient has John Cunnigham (JC) virus in their system
This virus is usually harmless but in low immune states can cause this fatal issue
Also seen in AIDS patients and those post-chemo
How are monoclonal antibodies such as tysabri administered
Given as an infusion on the wards
How do monoclonal antibodies work in MS
The monoclonal antibodies stop the inflammatory cascade by blocking the lymphocytes from passing through the BBB
What is demyelination
When there is damage to the myelin sheath of nerves
Relative preservation of axons
Leads to defects in the rate and consistency of conduction in the axons
What is the most common demyelinating disease
MS
What can cause demyelination
Inflammation - MS
Infarction
Trauma
What are the primary demyelinating conditions
MS
Acute disseminated encephalomyelitis - self-limiting and usually recover but may be left with a neurological deficit
Acute haemorrhagic leukoencephalitis - high mortality, rapidly fatal and acute form of ADE
What are the secondary demyelinating conditions
Progressive multifocal leukoencephalopathy- viral
Metabolic syndromes - CPM
Toxic insults - cyanide, CO2 etc
What is needed for a clinical diagnosis of MS
Need at least 2 distinct episodes occurring at different times
Excluded alternative diagnosis
A neurological defect implicating one neuro‐anatomical site
How does MS present on MRI
White lesions throughout the brain
Usually in the white matter
What causes internuclear opthalmoplegia
Brain stem lesions
What are plaques
Areas of brain inflammation which later undergo gliosis
Can be active or inactive
Well demarcated but irregularly shaped areas
Have an almost translucent appearance
Describe an active MS plaque
Will contain inflammatory cells and microglia
The microglia are recruited and engulf/digest the myelin
Ongoing demyelination
Yellow/brown appearance
Describe an inactive MS plaque
Have gliosis - scarred
Few remaining myelinated axons
Reduction in number of oligodendrocytes and axons
Which place has the highest incidence of MS in the world
Orkney!
How does migration affect MS risk (as it has geographical links)
If you move from a high prevalence area before the age of 12 your risk drops to that of the new area
This is not the case if over 18
So adults who migrate have the risk of their original home whereas children have the risk of their new home
How would optic neuritis present on eye examination
RAPD on the affected side
Reduced visual acuity on affected side
A pale disc may be seen after optic neuritis
Does MS present with upper or lower motor neurone signs
Upper
Spasticity, pyramidal pattern of weakness, brisk reflexes, extensor plantars, and if spinal cord involvement, sensory disturbance suggestive of partial cord involvement
Why is it important that MS patients stop smoking
Smoking adversely affects brain health and is associated with worse outcomes in MS
Vitamin D supplements should be suggested to all MS patients - true or false
True
Those who are low in vitamin D may have a more aggressive disease course and therefore vitamin D is recommended to all.
