Multiple Sclerosis Flashcards

1
Q

What is multiple sclerosis (MS)? [1]

A

idiopathic inflammatory demyelinating disease of the CNS that results in acute episodes of inflammation which are associated with focal neurological deficits

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2
Q

Name and describe the types of multiple sclerosis [5]

A
  1. Relapsing Remitting MS
    • unpredictable attacks which may or may not leave permanent deficits followed by periods of remission
  2. Primary Progressive MS
    • steady increase in disability without attacks
  3. Secondary progressive MS
    • initial relapsing-remitting MS that suddenly begins to have decline without periods of remission
  4. Progressive Relapsing MS
    • steady decline since onset with super-imposed attacks
  5. Benign MS
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3
Q

Name the syndromes that may lead to MS [4]

A
  1. Optic neuritis
  2. Clinically isolated syndromes
  3. Transverse myelitis
  4. Radiologically isolated syndromes
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4
Q

What is optic neuritis? [1]

A

Painful visual loss that comes on over a few days and may resolve after a few weeks

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5
Q

What is transverse myelitis and how does it clinically present? [4]

A
  • Inflammation of the spinal cord that can result in:
    • Weakness
    • Sensory loss
    • Incontinence
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6
Q

What are clinically isolated syndromes and what is the other cause of it (other than MS)? [2]

A
  1. Single episode of neurological disability due to focal CNS inflammation
  2. Can include optic neuritis and traverse myelitis
  3. May be a first attack of MS
  4. Can also happen after infection and be not related to MS
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7
Q

What criteria is required for MS to be diagnosed? [1]

A

MS is diagnosed when there is evidence of 2 or more episodes of demyelination disseminated in space and time

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8
Q

When should you suspect MS (“hidden relapses”)? [5]

A
  1. Optic neuritis/visual disruption
  2. Bell’s Palsy
  3. Labyrinthitis
  4. Sensory symptoms
  5. Bladder symptoms in young men/women without children
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9
Q

List the symptoms of MS under the following headings:

  1. central? [4]
  2. visual? [3]
  3. speech? [1]
  4. throat? [1]
  5. MSK? [3]
  6. sensation? [3]
  7. bowel? [3]
  8. urinary? [3]
A
  1. Central:
    • Fatigue
    • Cognitive impairment
    • Depression
    • Unstable mood
  2. Visual:
    • Nystagmus
    • Optic neuritis
    • Diplopia
  3. Speech:
    • Dysarthria
  4. Throat:
    • Dysphagia
  5. Musculoskeletal:
    • Weakness
    • Spasms
    • Ataxia
  6. Sensation:
    • Pain
    • Hypoesthesia
    • Paresthesia
  7. Bowel:
    • Incontinence
    • Diarrhoea or constipation
  8. Urinary:
    • Incontinence
    • Frequency or retention
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10
Q

What features would lead you to suspect something other than MS? [7]

A
  1. Sudden onset
  2. Peripheral signs - areflexia, glove and stocking distribution, muscle wasting, fasciculations
  3. Major cognitive involvement
  4. Reduced level of consciousness
  5. Prominent seizures
  6. Pyrexia/evidence of infection
  7. Normal MRI scan
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11
Q

What investigations should you use on a patient with suspected MS? [5]

A
  1. MRI brain and cervical spine with gadolinium contrast
  2. Lumbar puncture
  3. Bloods
  4. Visual evoked potentials
  5. CXR
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12
Q

How do you distinguish between demyelination dissemination in space and dissemination in time on MRI? [2]

A
  1. Indication of dissemination in space:
    • evidence of demyelination in 2 regions (e.g. periventricular and spinal cord)
  2. Indication of dissemination in time:
    • if enhancing and non-enhancing areas of demyelination are seen
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13
Q

Why would you do a CXR on a patient with suspected MS? [1]

A

to exclude sarcoidosis

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14
Q

What things are you testing for in the CSF? [4]

A
  1. CSF oligoclonal bands (need matched blood sample)
  2. CSF cell counts - exclude mimics
  3. CSF glucose (matched blood sample)
  4. CSF protein
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15
Q

What are oligoclonal bands and what type of presentation of these bands would indicate MS? [2]

A
  1. Immunoglobulin bands seen in blood and spinal fluid after protein electrophoresis
  2. Presence of bands in CSF but not blood suggests immunoglobulin production in CNS
    • supports diagnosis of MS but can be seen in other conditions
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16
Q

What blood tests would you carry out on a patient with suspected MS? [6]

A
  1. B12/Folate
  2. Serum ACE
  3. Lyme serology
  4. ESR/CRP - should be normal
  5. ANA/ANCA/Rheumatoid Factor
  6. Aquaporin-4 antibodies
    • (if transverse myelitis/optic neuritis)
17
Q

What does visual evoked potentials measure and what result would indicate optic neuritis? [2]

A
  1. Measure conduction of nerve signals in optic nerve to look for subclinical optic neuritis
  2. Conduction will be slower if a patient has had optic neuritis in the past
18
Q

What is the difference between a relapse vs. pseudo-relapse? [2]

A
  1. A relapse usually involves a new neurological deficit that lasts for more than 24 hours in the absence of pyrexia or infection
  2. A pseudo-relapse is the re-emergence of previous neurological symptoms or signs related to an old area of demyelination in the context of heat or infection
19
Q

What are the 2 steroid regimens used for MS relapses? [2]

A
  • 1g of IV methylprednisolone for 3 days

or

  • 500mg of oral methylprednisolone for 5 days AND
  • PPI for gastroprotection
20
Q

Name the 2 powerful drugs for MS [2]

A
  1. Alemtuzumab
  2. Natalizumab
21
Q

What are the 2 oral treatments for MS? [2]

A
  1. Fingolimod
  2. Dimethyl Fumarate
22
Q

What is cladribine? [1]

A

Old chemotherapy drug that targets B-cells and m]ay stop MS activity for many years

23
Q

What type of stem cell transplant can be used for very aggressive relapsing-remitting MS? [1]

A

Autologous haemopoietic stem cell transplant