Multiple sclerosis Flashcards
what are the disease modifying therapies for MS?
1st line: injectables
- glatiramer
- beta interferon
oral agents:
- teruflunimide
- dimethyl fumarate
biologics:
- natalizumab
describe the pathophysiology of MS.
immune mediated demyelination of the white matter of the CNS
plaques of demyelination and eventual axonal loss
CD4 cells mediated destruction of oligodendroglial cells and humeral response of myelin binding proteins
what risk factors are associated with MS?
female age 20-40yrs northern latitude vitamin D deficiency EBV autoimmune disease
what are the main presentations of MS?
Optic neuritis
Brainstem:
- UMN
- sensory involvement
- Cerebellar dysfunction (ataxia, nystagmus, vertigo)
- pons dysfunction (internuclear ophthalmoplegia)
Myelitis
- UMN below level of lesion
- patchy paraesthesia
- weakness below level of lesion
what features on brain/spinal MRI would you find in MS?
inflammation: contrast enhancing T2 hyperintensity with limited oedema
progressive process: atrophy and T1 hypointensity (black holes)
what investigations would you carry out if you suspected MS?
Brain/ spinal MRI
LP
if optic neuritis;
- Visual somatosensory evoked response
FBC, CRP/ESR: rule out other inflammatory cause
what feature on LP would you find in MS?
oligoclonal bands in the CSF and not the serum
what are the 2 diagnostic criteria for MS?
macdonalds criteria (MRI imaging) posers criteria (clinical)
what are differentials of MS?
acute disseminated encephalomyelitis (ADEM) neuromyelitis spectrum disorder adrenoleukodystrophy autoimmune i.e. SLE sarcoidosis infection i.e. lyme disease
what is acute disseminated encephalomyelitis?
brief but widespread attack of inflammation of the brain and spinal cord damaging the myelin
occurs post-infection
what is adrenoleukodystrophy?
x-linked condition
build up of fatty acid causes damage to myelin sheaths
what is neuromyelitis optic spectrum disorder?
autoimmune condition against the optic nerve and spinal cord (not the brain)
presence of aquaporin-4-antibodies
what is the first line treatment for primary progressive MS?
Ocrelizumab (biologic)
what is the treatment for an acute attack of MS?
methylprednisolone
1g IV every 24 hours for 3 days
refractory to treatment - plasma exchange
what re good prognostic factors for MS?
female
optic neuritis as first presentation
long period between 1st and 2nd relapse
few relapses in first 5 yrs
what are bad prognostic factors for MS?
male
older age
multifocal symptoms and signs
motor or cerebellar onset
what are the complications of MS?
bladder/bowel dysfunction immobility fatigue depression, anxiety cognitive dysfunction erectile dysfunction visual impairment osteopenia/osteoporosis
what medication could you give a patient with MS who has urinary incontinence?
anticholinergic i.e. Oxybutynin
what medication could you give a patient with MS who has severe fatigue?
Modefanil
advice exercise
what medication could you give a patient with MS who has erectile dysfunction?
sildenafil
what medication could you give a patient with MS who has severe tremor?
benzodiazepine i.e. Clonazepam
what medication could you give a patient with MS who has severe spasticity?
Baclofen or Bo Tox
what is the presentation of optic neuritis and what is the first line treatment?
visual field loss
dyschromatopsia (colour vision disturbance)
periocular pain
1st line: methylprednisolone
what is the pathophysiology of internuclear ophthalmoplegia?
lesion in the medial longitudinal fasciculous which blocks the connection between contralateral CN VI and ipsilateral CN III therefore affecting horizontal gaze
what are the features of internuclear ophthalmoplegia?
ipsilateral impaired adduction
contralateral nystagmus
what’s the treatment for neuromeylitis optica spectrum disorder?
immunosuppression (anti-CD20 Rituximab)
