Multiple Sclerosis

Question 1

What is MS?

Answer 1

• Chronic cell mediated autoimmune disorder
• Characterised by demyelination in the CNS
• Demyelination results in axonal loss

Question 2

What gender and age is MS more prevalent in?

Answer 2

• Females

- 20-40

Question 3

What are the different ways in which MS is categorised?

Answer 3

=> Relapsing-remitting disease:

• Most common form of MS
• Acute attacks followed by periods of remission

=> Secondary progressive disease:

• Relapsing-remitting patients have detoriated and developed neurological signs and symptoms between relapses
• Gait and bladder problems may be seen

=> Primary progressive disease:

• More common is older population
• Progressive detorioration from onset

Question 4

What are the clinical features of MS?

Answer 4

=> Most common presentation: Charcot’s Neurological Triad:

• Dysarthria (slurred or slow speech)
• Nystagmus (eyes make repetitive uncontrolled movements)
• Intention tremor

=> Visual:

• Optic neuritis
• Optic atrophy
• Uhthoff’s phenomena (worsening vision + raised temp)
• Internuclear opthalmoplegia

=> Sensory:

• Pins and needles
• Numbness
• Trigeminal Neuralgia
• Lhermitte’s syndrome (pain down limbs on neck flexion)

=> Motor:
- Spastic weakness

=> Cerebellar:

• Ataxia
• Tremor

=> Others:

• Urinary incontinence
• Sexual dysfunction
• Intellectual detoriation

Question 5

What are the investigations in suspected MS?

Answer 5

=> MRI - first line (along side bloods and other tests to exclude other diagnosis)
- White matter plaques due to myelin loss

=> CSF analysis
- Antibody levels high

=> Visual evoked potential

Question 6

What is the pathophysiology of MS?

Answer 6

• Type IV hypersensitivity reaction
• T cells pass BBB and bind to myelin, causing destruction
• Once bound, T cell becomes activated and releases cytokines

=> Immune cells involved in destruction:

• T cells
• B cells
• Macrophages

=> Regulatory T cells may briefly inhibit T cells allowing for periods of improvement

Question 7

What is the management of MS?

Answer 7

• No cure
• Treatment focuses on reducing frequency and duration of relapses through:

=> Lifestyle advice:

• Regular exercise
• Stop smoking
• Avoid stress

=> High dose steroids for acute relapses:

• PO or IV Methylpredinisolone for 5 days
• Shortens duration of a relapse

=> Disease modifying drugs:
- B Interferon
- Glatiramer Acetate acts as immune decoy
- Natalizumab inhibits migration of leucocytes
- Fingolimod prevents lymphocytes leaving lymph nodes
- Criteria for use of B interferon:
> Relapsing-remitting disease + 2 relapses in past 2 years + able to walk 100m unaided
> Secondary progressive disease + 2 relapses in past 2 years + able to walk 10m unaided

=> Symptom control:

• For spasticity => Baclofen or Gabapentin
• For tremors => Botulinum toxin
• For urgency => Self catheterisation
• For fatigue => Amantadine