Multiple Sclerosis Flashcards
What is multiple sclerosis?
Inflammatory plaques occurring in the central nervous system, distanced by space and time. It occurs at multiple sites at different times at least 30 days apart. These plaques cause demyelination which heal poorly and 80% of people develop progressive disability.
What are the causes and risk factors for MS?
T cell mediated autoimmune but still not completely clear
Increased risk with higher and lower latitude and adult migrants take their risk with them whilst children acquire the risk wherever they settle
Vitamin D and infection therefore thought to play a role (herpes type 6 and EBV)
3 times more common in women
Usually between ages of 20-40
What is the progression of MS?
Monosymptomatic at presentation
Relapsing remitting 85%, secondary progressive – when RR patients become progressive – occurs in 65% of RR patients and primary progressive which accounts for 10% of cases
What are the clinical features of MS?
Generally: Lethargy, cerebellar signs especially ataxia and tremor
Sensory: Paraesthesia, reduced vibration sense, trigeminal neuralgia and Lhermitte’s syndrome (paraesthesiae in limbs on neck flexion)
Motor: spastic weakness usually in the legs, myelitis (inflammation of the spinal cord), corticospinal tract and bladder also often involved
Sexual/GU: erectile dysfunction, anorgasmia, urine retention and incontinence
GI: swallowing problems and constipation
Eye: Optic neuritis (eye pain on movement and reduced central vision) – over time optic atrophy, Uhthoff’s phenomenon: worsening of vision following rise in body temperature
diplopia, hemianopia, bilateral internuclear ophthalmoplegia and pupil defects.
What are the requirements for diagnosis of MS?
McDonald Diagnostic criteria for MS
Diagnosis can be made on the basis of two or more relapses and either objective clinical evidence of two or more lesions or objective clinical evidence of one lesion together with reasonable historical evidence of a previous relapse.
What investigations can be done to look for MS?
MRI – sensitive but not specific for MS plaque detection – look for high signal T2 lesions, periventricular plaques, and Dawson fingers – hyperintense lesions perpendicular to the corpus callosum. Can exclude other causes e.g. cord compression.
CSF test looking for oligoclonal bands of IgG on electrophoresis
Delayed but well preserved visual, auditory and somatosensory evoked potentials
How are acute episodes of MS managed?
Acute treatment – methylprednisolone 0.5-1g for 3-5 days but should be used sparingly
What lifestyle advice is often given to patients with MS?
Lifestyle advice including regular exercise, no smoking and avoiding stress
What disease modifying drugs can be offered in MS?
Disease modifying drugs
Beta-interferon – reduced relapse rate but must have relapsing remitting disease + 2 relapses in past 2 years and able to walk 100m unaided OR secondary progressive disease + 2 relapses in past 2 years + able to walk 10m aided/unaided.
Glatiramer acetate- acts as an immune decoy
Natalizumab – prevents leukocytes crossing the BBB
Fingolimod – prevents leukocytes from leaving lymph nodes
How can we treat spasticity in MS?
Spasticity – baclofen or gabapentin, tizanidine or dantrolene are 2nd line, final option benzos. Physiotherapy is important.
How can we treat tremor in MS?
Tremor – botulinum injections
How do we treat urinary problems in MS?
Urgency/frequency – teach self-catheterisation if significant residual volume when emptying otherwise anticholinergics may improve frequency
How is fatigue managed in MS?
Fatigue – amantadine, CBT, mindfulness, or exercise
What is oscillopsia and how is it managed in MS?
Oscillopsia (oscillating visual fields) – gabapentin
