MULTIPLE SCLEROSIS Flashcards
What is MS?
- inflammatory DEMYELINATING d.o of the cns
When is the usual time of onset of MS and in whom?
- females
- 30s and 40s
How does MS present as on imaging?
MRI
- plaques disseminated in time and place
What predisposes you to MS?
- a monozygotic twn= 1 in 3 chance
- 1st degree relative== 12% chance
GENETIC makeup is HUGE in pathology
Main clinical fts of MS?
- optic neuritis
- pyramidal dysfxn (h/t and weakness)
- sensory symptoms
- Lr urinary tract dysfxn
- cerebellar & brain stem fts
- cognitive impairment
What occurs from pyramidal dysfxn?
- incr. TONE
- spasticity
- weakness
- involves EXTENSORS of UPPER limbs
- flexors of lower limbs
What occurs with optic neuritis?
- PAINFUL vision loss
- most will improve (1-2weeks)
WHat is the 1st presentation of MS?
- pain of moving eyes
- i.e. OPTIC NEURITIS
How to test for optic neuritis?
- shine light in both the eyes (alternating between the 2)
—-find the eye with the pathology NOT constricting with the light
= RAPD (relative afferent pupillary defect)
Are sensory symtoms present in MS?
YES
What are some sensory symtptoms?
- PAIN
- paraesthesia (burning feeling/ water going down the leg)
- DORSAL column loss (VIBRATION and PROPRIOCEPTION)
- numbness
- trigeminal neuralgia
What are some symptoms of cerebellar dysfxn?
- ataxia
- nystagmus
- dysarthria
- intention tremor
- past pointing
- pendular reflexes
- dysdiadokinesis
How does brain stem dysfxn present as?
- DIPLOPIA (VI nerve palsy)
- facial weakness (VII palsy)
What is affected in internuclear ophthalmoplegia to result in DIPLOPIA?
- pathology of the MEDIAL LONGITUDINAL FASCICULUS
distorts the binocular vision
What is seen clinically with INO?
- failure of ADDUCTION
> DIPLOPIA
——nystagmus in normal abducting eye
—lag
WHat urinary tract symptoms are seen?
- nocturia
- freq. (d.t irritability(
- urgency
- URGE incontinence
- retention (d.t incr. tone)
How do you manage fatugability in MS?
- amantadine
- MOdafinil is SLEEPY
- HYPERBARIC oxygen
How is the urinary tract dysfxn managed?
- bladder drill
- anti-cholinergics (OXYBUTIN–> retention causing detrusor overactivity)
- desmopressin (given for LONG journeys)
- catheterisation
Criteria for dx MS?
at least 2 episodes suggestive of demyelination
dissemination in time and place
What ivx can be done for confirming MS dx?
-Clinical
- MRI
CSF
- NEUROPHYSIOLOGY
- BLOODTEST
What are some ddx for MS?
- vasculitis
- granulomatous disorder
- vascular disease
- tumor
- infection (HIV, LYME)
- metabolic disease (B12 folate def.)
What blood tests can be done?
- plasma viscosity, FBC and CRP should be NORMAL
- renal, liver and bone profile
- auto anti-body screen
- borellia, HIV, syphilis serology
- B12 and folate
- Vitamin D
What should be looked for in CSF?
- raised proteins
- incr. proportion of immunoglobulins
- presence of oligoclonal bands in the CSF
- in 90% of cases
How variable is relapse?
- could happen in one year or 10 years
What does prophylactic rx for MS entail?
- initiation of disease modifying therapy
- escalation to second line
- MRI
How is a MILD acute exacerbation treated?
symptomatically
How is a MODERATE acute exacerbation treated?
ORAL steroids
- oral methylprednisolone (0.5g x 5 days)
How is a SEVERE acute exacerbation treated?
- admit
- IV steroids
—-just to SHORTEN the length of the ACUTE relapse (does not mean pt returns to baseline)
How is pyramidal dysfxn treated?
- physiotherapy
- occupational therapy
- ANTI-SPASMODIC agent
How is spasticity managed?
- physiotherapy
- oral medication (BACLOFEN/GABAPENTIN)
- intrathecal BACLOFEN/ PHENOL (bed bound pts)
- cannabis and botulinum toxin (apparent help)
How are sensory symtoms treated?
1- anticonvulsants (GABAPENTIN) 2- anti-depressant (amitriptyline) 3- TENS machine 4- Acupuncture 5- Lignocaine infusion
Why are urinary symtpoms presented in MS?
- d.t INcr. tone at bladder neck
- detruser hypersensitivity
- detruser sphyncteris dyssenergia (bladder and urethra contracts simultaneously)
What is FIRST line for MS disease modifying therapy?
- Beta Interferon
- Glatiramer acetate
- Tecfidera
- Natalizumab
Name interferons?
avonex
rebif
How effective are interferon?
- decr. relapse rate by 1/3
- severity of relapse decr. by 50%
What is first line for relapse-remitting MS?
- TECFIDERA
(oral agent)
—-reduces relapse by 44%
When to move to second line?
- emergence of new plaques
- foundon mri
Name the second line rx for MS.
- Fingolimod/Cadrabine
- ORAL agents
-monoclonal antibody (Tysabri), ocrevus
How effective is the second line?
> 50% reduction in relaspe rate
- significant effect in disease progression
What is given in those with high disease activity and rapidly evolving severe relapsing remitting MS?
single disease modifying therapies
Tysabri
Decribe the inflammatory cascade in MS. `
- immune cells pass the BBB
- these cells re-activate and produce CYTOKINE
- immune cells MOUNT and autoimmune attack against myelin
What is the mode of axn of Tysabri?
- prevents leukocyte migration ACROSS BBb
- prevents leukocyte priming and activation
- modulates leukocyte apoptosis
