Multiple Sclerosis Flashcards
What is MS?
Inflammatory Demyelinating Disorder
Who is likely to get MS?
M:F - 1:3
30-40s
What is the usually pattern of presentation in MS?
Relapsing and remitting symptoms present then disappear.
What is the rarest form of MS?
Primary - no relapse
List clinical features of MS.
Pyramidal dysfunction Optic neuritis Sensory symptoms Cognitive impairment Cerebellar dysfunction Brain stem issues Urinary incontinence Fatigue
What pyramidal dysfunction is associated with MS?
Increased tone spasticity
Weakness
Flexor and extensor both affected the same.
What occurs in MS related optic neuritis?
Painful vision loss for 1-2 week
Most improve
Look for RAPD -Relative Afferent Pupillary Defect
What sensory symptoms are associated with MS?
Pain Paraethesia pins and needles Proprioception and vibration Numbness Trigeminal Neuralgia
What cerebellar dysfunction is associated with MS?
Dysarthria Ataxia Nystagmus - involuntary eye movement Intention tremor Pendular reflex
What brain stem issues are associated with MS?
Diplopia
VI palsy
Facial weakness VII
Why do some patients with MS present with Internuclear opthalmoplegia?
Disturbance of binocular vision
Failure of abducens due to VI palsy
Nystagmus in abduction eye
Why do MS patients present with urinary incontinence?
Increased tone at bladder neck and hypersensitivity
What is required for a diagnosis of MS?
At least 2 episodes suggestive of demyelination and alternative diagnosis excluded.
Either one on MRI and one clinical or both on MRI
What tests are undertaken in a suspected MS patient?
MRI CSF Neurophysiology Bloods
What are some differential diagnosis’s in a patient with MS like symptoms?
Vasculitis Granulomatous Structural lesions Infection Metabolic disorders B12 deficiency Folic acid deficiency
What are you looking for in the CSF of someone with MS?
Unmatched oligoclonal bands
If someone presents with acute mild MS what is the treatment?
Purely symptomatic
If someone presents with acute moderate MS what is the treatment?
Oral steroids
If someone presents with acute severe MS what is the treatment?
IV steroids and admission
Symptomatic pyramidal dysfunction is treated how?
Physiotherapy
Baclofen - spasticity
Tizanidine -spasticity
Botulinum Toxin - spasticity
What treatment is given for the sensory symptoms of MS?
Anticonvulsant - Gabapentin
Antidepressant - Amitriptyline
Acupuncture
Lignocaine infusion
What can be used for the treatment of urinary incompetence?
Anticholinergics
Catheterisation
Bladder training
What is the first line disease modifying drug?
Tecfedira
Aubagia
INFβ IV
What are second line disease modifying drugs used in MS?
Monoclonal antibodies i.e Lemtrada
Fingolimod
When are second line disease modifying drugs used?
In either resistant or severe early onset 2 episodes within a year.
What are the third line disease modifying drugs?
Mitoxantrone
Stem cell transplant
When are the third line disease modifying drugs used?
Very severe relapsing disease
What is Tecfidera ?
1st line
Oral agent
44% reduction in symptoms
What is INFβ?
Interferron β
SC or IM
Decreases rate and severity of relapses
Very few side effects
What is Fingolimod?
2nd line
Oral agents
Toxicity means not 1st line
What are some of the side effects of fingolimod?
Cardia toxicity
Lower white cell count
Hypertension
List some common monoclonal antibodies.
Rituximab
Natlilizumab
When is Rituximab used?
Highly active relapsing and remitting MS
How does Natilizumab work
Bings to α4 integrin
Prevents binding of lymphocyte to the VCAM on blood vessel wall
Prevent lymphocyte migration out of the blood vessel.
Describe plaques related to MS.
Well circumscribed and demarcated with an irregular shape often glassy and translucent.
Massive variation in size
What does an active plaque appear like?
Perivascular inflammation
Microglia
Ongoing demyelination
What does an inactive plaque appear like?
Gliosis
Few myelinated axons
Reduced oligodendrocytes
What is the association of MS with latitude ?
Further from the equator there is an increase in prevalence of MS.
What is another primary cause of demyelination which isn’t MS with a low mortality?
Acute disseminate Encephalomyelitis
Self limiting, full recovery with some defecits
What is another primary cause of demyelination which isn’t MS with a high mortality?
Acute haemorrhage leukoencephalitis
What is a secondary cause of demyelination?
Central pontine myoclinosis
What causes Central Pontine myoclinosis?
Too fast correction of hyponatraemia
What virus can lead to. secondary form of demyelination?
JC virus
What can lead to a toxic secondary form of demyelination?
Organic solvents
List some environmental factors related to MS?
Vitamin D deficiency
Viral triggers e.g. EBV
List some genetic factors related to MS?
HLA DRB
Polymorphism in Interleukins
Familial link
What interleukins when mutated are linked to an increased risk of MS?
IL-2
IL-7
What forms the oligoclonal bands found in the CSF of someone with MS?
IgG
