Multiple sclerosis

Question 1

what are the disease modifying therapies for MS?

Answer 1

1st line: injectables

• glatiramer
• beta interferon

oral agents:

• teruflunimide
• dimethyl fumarate

biologics:
- natalizumab

Question 2

describe the pathophysiology of MS.

Answer 2

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

Question 3

what risk factors are associated with MS?

Answer 3

female
age 20-40yrs
northern latitude
vitamin D deficiency
EBV
autoimmune disease

Question 4

what are the main presentations of MS?

Answer 4

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

Question 5

what features on brain/spinal MRI would you find in MS?

Answer 5

inflammation: contrast enhancing T2 hyperintensity with limited oedema

progressive process: atrophy and T1 hypointensity (black holes)

Question 6

what investigations would you carry out if you suspected MS?

Answer 6

Brain/ spinal MRI

LP

if optic neuritis;
- Visual somatosensory evoked response

FBC, CRP/ESR: rule out other inflammatory cause

Question 7

what feature on LP would you find in MS?

Answer 7

oligoclonal bands in the CSF and not the serum

Question 8

what are the 2 diagnostic criteria for MS?

Answer 8

macdonalds criteria (MRI imaging)
posers criteria (clinical)

Question 9

what are differentials of MS?

Answer 9

acute disseminated encephalomyelitis (ADEM)
neuromyelitis spectrum disorder 
adrenoleukodystrophy 
autoimmune i.e. SLE
sarcoidosis 
infection i.e. lyme disease

Question 10

what is acute disseminated encephalomyelitis?

Answer 10

brief but widespread attack of inflammation of the brain and spinal cord damaging the myelin

occurs post-infection

Question 11

what is adrenoleukodystrophy?

Answer 11

x-linked condition

build up of fatty acid causes damage to myelin sheaths

Question 12

what is neuromyelitis optic spectrum disorder?

Answer 12

autoimmune condition against the optic nerve and spinal cord (not the brain)

presence of aquaporin-4-antibodies

Question 13

what is the first line treatment for primary progressive MS?

Answer 13

Ocrelizumab (biologic)

Question 14

what is the treatment for an acute attack of MS?

Answer 14

methylprednisolone
1g IV every 24 hours for 3 days

refractory to treatment - plasma exchange

Question 15

what re good prognostic factors for MS?

Answer 15

female
optic neuritis as first presentation
long period between 1st and 2nd relapse
few relapses in first 5 yrs

Question 16

what are bad prognostic factors for MS?

Answer 16

male
older age
multifocal symptoms and signs
motor or cerebellar onset

Question 17

what are the complications of MS?

Answer 17

bladder/bowel dysfunction
immobility 
fatigue 
depression, anxiety 
cognitive dysfunction
erectile dysfunction
visual impairment 
osteopenia/osteoporosis

Question 18

what medication could you give a patient with MS who has urinary incontinence?

Answer 18

anticholinergic i.e. Oxybutynin

Question 19

what medication could you give a patient with MS who has severe fatigue?

Answer 19

Modefanil

advice exercise

Question 20

what medication could you give a patient with MS who has erectile dysfunction?

Answer 20

sildenafil

Question 21

what medication could you give a patient with MS who has severe tremor?

Answer 21

benzodiazepine i.e. Clonazepam

Question 22

what medication could you give a patient with MS who has severe spasticity?

Answer 22

Baclofen or Bo Tox

Question 23

what is the presentation of optic neuritis and what is the first line treatment?

Answer 23

visual field loss
dyschromatopsia (colour vision disturbance)
periocular pain

1st line: methylprednisolone

Question 24

what is the pathophysiology of internuclear ophthalmoplegia?

Answer 24

lesion in the medial longitudinal fasciculous which blocks the connection between contralateral CN VI and ipsilateral CN III therefore affecting horizontal gaze

Question 25

what are the features of internuclear ophthalmoplegia?

Answer 25

ipsilateral impaired adduction

contralateral nystagmus

Question 26

what’s the treatment for neuromeylitis optica spectrum disorder?

Answer 26

immunosuppression (anti-CD20 Rituximab)