Multiple sclerosis Flashcards
Describe MS?
- Inflammatory demyelinating disease
- Presence of episodic neurological dysfunction in at least 2 areas of CNS
- Brain, spinal cord, optic nerve
- Dissemintated in space/time:
- ie occuring at multiple sites, with >29 days between attacks
Cause of MS?
- Exact aetiology unknown
- Genetic factors (>30% concordance in identical twins)
- Environmental factors (increasing incidence with latitude in the world)
- Roles of vitamin D and infection
Mean age of onset?
Gender distribution?
30yrs average onset
3x more common in women
Describe the presentastion of MS?
- Usually monosymptomatic
- Unilateral optic neuritis
- Corticospinal tract and bladder involvement is common
- Symptoms may worsen with heat (bath/exercise)
What is optic neuritis?
- Inflammation of the optic nerve
- Pain on eye movement
- Reduced rapid central vision
Describe the diagnostic criteria for MS
Describe the tests for investigation of MS?
- Depends on the presenting symptoms
- MRI:
- Sensitive but not specific for plaque detection
- Can exclude other causes including cord compression
- CSF:
- Oligoclonal bands of IgG on electrophoresis that are not present in serum
- Suggests CNS inflammation
- Oligoclonal bands of IgG on electrophoresis that are not present in serum
- Delayed visual, auditory and somatosensory evoked potentials
Describe the progression of MS?
- Relapsing-remitting course
- With time remission between relapses becomes incomplete -> disability
- Pregnancy does not alter progression rate
- May reduce during pregnany then increase for a few months after
- Then returns to normal course
Name this type of MS?
Relapsing remitting
Name this type of MS?
- Secondary progressive
- Symptoms worse over time, with or without relapses and remissions
- People progress to this from relapsing remitting
Name this type of MS?
- Primary progressive (PPMS)
- Slowly worsening symptoms from the beginning
- No relapses or remissions
Name this type of MS?
- Progressive relapsing (PRMS)
- Steady decline with relapses inbetween
- No remissions
Name some lifestyle advice for MS that patients can receive?
- Take multivitamin containing vitamin D
- Stop smoking
- Avoiding stress
Approaches to the management of MS?
- Disease-modifying drugs
- Treating relapses
- Symptom control
Disease modifying drugs for MS?
- Mild-moderate disease
- Interferon-β
- Dimethyl fumarate
- More severe disease
- Monoclonal antibodies
- Alemtuzumab
- Natalizumab
- Monoclonal antibodies
Treating relapses in MS?
- Methylprednisolone
- 3-5 day course
- Shortens length of acute relapses, but does not effect prognosis
- Should not be used more than twice/year
- SEs of steroids
Name some symptoms that may need controlled in MS?
- Spasticity
- Tremor
- Urgnecy/frequency
- Fatigue
How can spasticity be treated in MS?
- 1st line: Baclofen or gabapentin
- 2nd line: Tizanidine
- 3rd line: Benzodiazepines
How can tremor be treated in MS?
- Botulinum toxin type A injections
- Improve arm tremor and functioning
How can fatigue be treated in MS?
- Amantadine
- Cognitive based therapy
- Exercise
Clinical features of MS?
Eponyms of MS?
- Pulfrich effect
- Lhermitte’s sign
- Devic’s syndrome
- Charles Bonnet syndrome
- Uhthoff’s phenomenom
- Argyll Robertson pupil
Describe Devic’s syndrome?
- (Neuromyelitis optica)
- MS variant with transverse myelitis
- Loss of motor, sensory, autonomic, reflex, sphincter function below lesion level
- Optic atrophy
- Anti-aquaporin 4 antibodies (698 oxford handbook)
Describe Lhermitte’s sign?
- Neck flexion causes electric shocks in trunk/limbs
- Also present in cervical sponylosis, cord tumours and B12 deficiency
Describe Uhthoff’s phenomenom in MS?
Worseneing of symptoms with head (bath, exercise)
Describe Charles Bonnet syndrome in MS?
- Reduced acuity/temporal blindness
- +/- complex visual hallucinations of facesm as well as animals, plants and trees
Describe Pulfrich effect in MS?
- Unequal eye latencies
- Causes disoreintation in traffic:
- Straight trajectories seem curved
- Distances are misjudged on looking sideways
Describe Argyll Robertson pupil in MS?
- Pupil is constrictive and unreactive to light
- But reacts to accomodation
- The iris may be patchily atrophied, irregular and depigmented
- Occurs in MS, neurosyphilis, DM, HIV, sarcoidosis
- (prostitutes pupil - accomodates but does not react
Risk factors for MS?
- Strong
- Female
- Northern latitude
- Weak
- Genetic factors
- Smoking
- Vitamin D deficiency
- Autoimmune disease
- Epstain barr virus (EBV)
Differentials for MS?
- Fibromyalgia
- Sleep disorders
- Vitamin B12 deficiency
- Peripheral neuropathy
- Guillain-Barre syndrome
Describe the first line investigations into someone with suspected MS?
- MRI brain:
- Hyperintensities in periventricular white matter
- MRI spinal cord:
- Demyelination lesions (especially cervical SC)
- FBC, TSH, vitamin B12 (all normal in MS)
Name some second line tests for investigating someone with MS?
- Anti-neuromyelitis optica antibody
- Present in Devic syndrome
- CSF evaluation
- Glucose, protein, cell count normal
- Oligoclonal bands and elevated CSF IgG
- Evoked potentials (most common visual)
- Prolongation of conduction
- Asymmetrical prolongation in visual evoked potentials
Treatment for acute relapse affecting function in MS?
Methylprednisolone + plasma exchange
First line treatment for relapsing-remitting MS?
- Immunomodulators
- lifestyle modifications +/- non-pharmacological treatmeats
First line treatment for secondary progressive MS?
- 1st line:
- Siponimod or methylprednisolone
- 2nd line:
- Cladribine
