multiple sclerosis

Question 1

definition

Answer 1

Multiple sclerosis (MS) is defined as an inflammatory demyelinating disease characterised by the presence of episodic neurological dysfunction in at least two areas of the central nervous system (brain, spinal cord, and optic nerves) separated in time and space.

Question 2

symptoms

Answer 2

Usually monosymptomatic:
unilateral optic neuritis (pain on eye movement and rapid decreasing central vision); numbness or tingling in the limbs; leg weakness; brainstem or cerebellar symptoms (eg diplopia, ataxia).

symptoms can occur in GI tract as well (swallowing disorders, constipation), and with sexual activity as well (erectile dysfunction, anorgasmia), with the urinary tract (urinary incontinence, retention).

Symptoms may worsen with heat (eg hot bath) or exercise. Rarely polysymptomatic.

Progression: Early on, relapses (which can be stress induced) may be followed by remission and full recovery. With time, remissions are incomplete, so disability accumulates. Steady progression of disability from the outset also occurs, while some patients experience no progressive disablement at all.

Poor prognostic signs: Older females; motor signs at onset; many relapses early on; many MRI lesions; axonal loss.

Question 3

investigations

Answer 3

1st investigations:

• MRI brain
• MRI spinal cord
• FBC
• comprehensive metabolic profile
• TSH
• vit B12

Question 4

treatment

Answer 4

acute relapse:
1. methylprednisolone (start on IV 3 times a day)
++ plasma exchange

relapsing-remitting MS:
1. immunomodulators (teriflunomide, interferon beta 1a/b, finoglimod)

secondary progressive MS:

1. siponimod (immunomodulator) or methylprednisolone
2. cladribine (but increases risk of malignancy and could cause fetal harm, do not use without contraception)

primary progressive MS:
1. consider ocrelizumab (similar to rituximab)
+ treat symptoms as necessary:
=> nerve pain: pregabalin
=> tremor: propanolol (risk of hypertension, depression), primidone (sedating), clonazepam (sedating, addictive)
=> gait impairment: physio + fampridine
=> spasms: physio/stretching + baclofen/tizanidine/clonazepam (only medicate if necessary!)

Question 5

complications

Answer 5

• UTI
• visual impairment
• osteopenia and osteoporesis (could be due to the corticosteroid use or due to MS itself, unsure.)
• depression
• erectile dysfunction

Question 6

prognosis

Answer 6

It is very difficult to prognosticate effectively for MS patients. Some individuals have a very benign course and/or respond well to treatment, whereas others become rapidly disabled within several years of diagnosis. One long-term follow-up study of a pivotal interferon beta-1b trial in MS patients has suggested that long-term physical and cognitive outcomes may be largely determined early in the disease course.

Various factors favouring better prognosis have been supported by older demographic studies done in the pre-treatment era and include female sex, sensory symptoms, or optic neuritis at onset. Poorer prognostic factors include frequent relapses and motor or cerebellar onset. Newer studies have looked at lesion burden on magnetic resonance imaging at onset, indicating that a higher lesion burden at onset portends a poorer prognosis, particularly for cognitive outcomes